C  LIBRARY 


V 


UNIVERSITY  OF 
CALIFORNIA 

SAN  DIEGO 


DATE  DUE 


GAYLORD 


WO  100  S478*  1889 

m  mm  mi 

3  1822  01103  7421 


Digitized  by  the  Internet  Archive 

in  2008  with  funding  from 

Microsoft  Corporation 


http://www.archive.org/details/experimentalsurgOOsenn 


EXPERIMENTAL  SURGERY. 


NICHOLAS    SENN,  M.  D.,  Ph.  D., 

ATTENDING    SUBOEON     MILWAUKEE     HOSPITAL;      PKOFESSOE    OF    THE     PEINOIPLES    OF 

SUBGEBY    AND    SUBGIOAL    PATHOLOGY,    IN    BUSH    MEDICAL 

COLLEGE,    CHICAGO. 


CHICAGO: 

W.  T.   KEENER, 

1)6  Washington  Stbeet. 
18  89. 


Copyright,  1889,  by  W.  T.  Keener. 


PUBLISHER'S  ANNOUNCEMENT. 


For  a  number  of  years  the  author  has  carried  on  experimental 
surgical  work  with  a  view  to  stimulate  others  to  work  in  the  same 
direction,  as  experimental  research  is  one  of  the  most  important 
factors  in  solving  scientific  problems.  As  a  necessary  complement 
to  clinical  observation,  it  tends  to  purify  science  from  the  sterile 
a  priori  reasons  and  theories  with  which  medical  science  has  in 
former  times  been  heavily  loaded  down. 

The  different  parts  of  the  volume  have  been  published  from 
time  to  time  in  the  Transactions  of  the  American  Surgical  Associa- 
tion, and  in  periodicals  not  readily  accessible  to  the  majority  of  the 
medical  profession.  It  has  therefore  been  deemed  desirable  to  bring 
together  in  one  volume  the  work  done  by  the  author  in  this  direc- 
tion, in  the  hope  that  the  practical  surgeon  of  to-day  may  obtain 
from  it  aid  in  cases  which  he  may  at  any  time  meet,  that  the  general 
practitioner  may  be  guided  by  it  in  diagnosis,  and  that  the  medical 
student  may  learn  from  its  pages  how  to  treat  questions  according 
to  the  methods  and  laws  of  true  science. 


CONTENTS 


Fbactubes  of  the  Neck    of   the    Femub,  with   Special    Reference  to 
Bony  Union  afteb  Intba-Capsulab  Fbactube. 

PAGE 

I.     Experiments  on  Animals,   -----  1 

II.     Bony  Union  after  Impacted  Intra-Capsular  Fracture,  -        7 

III.  Anatomy  of  the  Neck  of  the  Femur,                        -             -  10 

IV.  Classification  of  Fractures,       -            -             -             -  -      20 
V.     Relative  Number  of  Intra-  and  Extra-Capsular  Fractures,  22 

VI.     Incomplete  Fractures,  -             -             -             -             -  -      25 

VII.     Impacted  Fractures,             -----  27 

VIII.     Predisposing  Causes,     -            -            -            -            -  -      3(5 

IX.     Exciting  Causes,      ------  37 

X.     Senile  Osteo-Porosis,     -             -             -             -             -  -      38 

XI.     Symptoms  of  Fracture,        -----  44 

1.  Subjective  Symptoms,         -             -             -             -  -      45 

a.  Pain,             ------  45 

b.  Loss  or  Impairment  of  Function,       -             -  -      46 

2.  Objective  Symptoms,    -----  4G 

a.  Swelling  and  Deformity,          -             -  -      47 

b.  Suggillation,            -----  47 

c.  Eversion,            -             -             -             -             -  -      47 

d.  Shortening,              -----  49 

e.  Change  of  Position  of  Trochanter  Major,      -  -      51 

f.  Alteration  of  Motion,         -             -                         -  51 

g.  Fascia  Lata,     -             -            -             -             -  -      52 

XII.     Diagnosis,     -----                           -  52 

XIII.  Production  of  Callus,     -             -  58 

XIV.  Can   Loose   Detached  Pieces  of   Bone  Produce  Callus,  and 

Aid  in  Effecting  Bony  Union,  62 

XV.     Specimens  of  Bony  Union  after  Intra-Capsular  Fracture,    -      68 

XVI.     Non-Union  after  Intra-Capsular  Fracture,              -              -  80 

XVII.     Bony  Union  after  Intra-Capsular  Fracture,    -  -      83 


VI. 


CONTENTS. 


XVIII.     Treatment,  -  ... 

1.  Immediate  Reduction  and  Coaptation, 

2.  Fixation,  .... 

3.  Lateral  Pressure,     ... 

4.  Direct  Fixation  by  Bone  Pegs, 


PAGE 

89 
92 
92 
93 
95 


ExPEBIMENTAL    RESEARCHES    ON     ClCATBIZATION      IN      BlOOD-VeSBELS     AFTEB 

LlGATDBE.               ........  101 

I.     History  of  the  Ligature,      ...             -  103 

II.     Histology  of  Blood-Vessels,      -                           ...  113 

1.  Intima,  -------  114 

2.  Media,           ...                                      -             -  116 

3.  Adventitia,         -            -            -            -            -  118 
III.     Intermediate  Ligature,  Ligature  en  masse,    -             -             -  120 

IV.     Immediate  or  Direct  Ligature,       -             -                           -  121 

V.     Scarpa's  Aplatissement,             -  121 

VI.     Double  Ligature,      ...             -                           -  122 

VII.     Momentary  Ligature,    ------  123 

VIII.     Temporary  Ligature,           -----  123 

IX.     Permanent  Ligature,     ------  126 

X.     Aseptic  Ligature,     -            -                          ...  129 

XL     Thrombosis  after  Ligature,       -----  135 

XII.     Organization  of  Thrombus,             ....  137 

Formation  of  Cicatrix  in  Blood-Vessels  after  Ligature,         -  138 


XIII. 

XIV. 

XV. 

XVI. 

XVII. 


Formation  of  Cicatrix  by  Adhesive  or  Plastic  Inflammation,  139 

Formation  of  Cicatrix  from  Fibrin,     -             -             -  141 

Formation  of  Cicatrix  from  White  Blood-Corpuscles,      -  143 

Formation  of  Cicatrix  from  Red  Blood-Corpuscles,  -             -  147 

XVIII.     Formation  of  Cicatrix  from  Immigration  Corpuscles,     -  147 

XIX.     Formation  of  Cicatrix  from  Endothelia,          -             -             -  150 

XX.     Formation  of  Cicatrix  from  Connective  Tissue,  -             -  165 

XXI.     Primary  Union  in  Blood- Vessels  after  Ligature,         -             -  170 

XXII.     Experiments,            -----  172 

Double  Ligation  of  Arteries,         -  173 

Double  Temporary  Ligation  of  Arteries,       -             -  178 

Double  Ligation  of  Veins,              ....  180 

Double  Temporary  Ligation  of  Veins,                         -  182 

Ligation  of  Artery  and  Vein  in  a  Horse,               -             -  184 

XXIII.     Remarks,      -                         ...             -  184 

1.  Effect  of  Suppuration,        -----  184 

2.  Thrombus,          ------  185 


CONTENTS.  Vll. 

PAGE 

XXIII.  Remarks,  (Continued),         -----  184 

3.  Ligature,      -             -             -             -             -             -             -  187 

4.  Extra-Vascular  Cicatrix,            ...             -  188 

5.  Intra-Vascular  Cicatrix,      -----  188 

6.  Temporary  Ligature,    -----  190 

7.  Microscopical    Appearance   of    Recent    Intra-Vascular 

Cicatrix,             -             -             -             -             -             -  191 

XXIV.  Practical  Suggestions,        -----  193 
An  Experimental,  and  Clinical  Study  of  Air-Embolism,            -             -  197 

I.     The  Immediate  Cause  of  Death  in  Rapidly  Fatal  Embolism,  198 

II.     History  of  Air-Embolism,          -             -             -             -             -  204 

III.  Intravenous  Production  of  Air,      -  207 

IV.  Effect  of  the  Heart  and  Respiration  on  the  Venous  Circu- 

lation,          -             -             -             -             -             -             -  208 

V.     Aspiration  of  Air  into  the  Superior  Longitudinal  Sinus,  214 

VI.     Experiments,      -------  216 

VII.     Practical  Suggestions,         -----  223 

VIII.     Immediate   Cause   of   Death   after  Intravenous  Insufflation 

of  Air,   - 227 

IX.     Intra-Arterial  Insufflation  of  Air,    -             -            -            -  233 

X.     Clinical  Study  of  Air-Embolism,                         -             -             -  236 

External  Jugular,          -----  239 

Internal  Jugular,    ------  240 

Facial  Vein,       ------  241 

Axillary  Vein,          -                                        -             -             -  242 

Anterior  Thoracic  Vein,            ...             -  243 

Superficial  Cervical  Vein,                ...             -  244 

Femoral  Vein,  ------  244 

Uterine  Veins,         ------  245 

Pulmonary  Vein,           -  248 

Superior  Longitudinal  Sinus,         -  249 

XI.     Experiments  on  Venous  Air-Embolism,    -             -             -  252 

XII.     Experiments  on  Arterial  Air-Embolism,          -             -             -  257 

XIII.  Direct  Intra-Cardiac  Insufflation  of  Air,    -             -             -  261 

XIV.  Aspiration  of  Right  Ventricle  for  Air-Embolism,      -             -  262 
XV.     Catheterization  and  Aspiration  of  Right  Auricle  for  Venous 

Air-Embolism,         -             -                           -             -             -  268 

XVI.     Prophylactic  Treatment  of  Air-Embolism,  272 

1.  Position,       -             -             -                           -             -             -  272 

2.  Compression,     ------  274 

3.  Ligature,      -------  277 

4.  Aseptic  Tampon,            -----  277 


Via.  CONTENTS. 

PAGE 

XVII.     Operative  Treatment  of  Air-Embolism,  -  -  -  278 

1.  Prevention  of  Farther  Ingress  of  Air,  -  -  278 

2.  Cardiac  Stimulation,  -  -  -  -  -  279 

3.  Venesection,       -  -  •  -  -  -  280 

4.  Aspiration  of  Air  from  the  Heart,  -  -  -  282 

XVIII.     Summary,    -------  286 

The    Subgeby    of    the    Pancbeas,    as    Based   upon    Expebiments    and 

Clinical  Reseabches,        ------  289 

I.     Comparative  Anatomy  of  the  Pancreas,         -  -  -  289 

II.     Development  of  the  Pancreas,       -  291 

III.  Physiology  of  the  Pancreas,     -----  295 

IV.  Experiments  on  the  Pancreas,        ...  -  299 

1.  Complete  Section,  -  -  ...  300 

2.  Laceration,  -.--..  303 

3.  Comminution,  ------  304 

4.  Complete  Extirpation,  -  306 

5.  Partial  Extirpation,  -  311 

6.  Obliteration  of  Pancreatic  Duct  by  Elastic  Compression,  314 

7.  External  Pancreatic  Fistula,  ...  328 

8.  Internal  Pancreatic  Fistula,     -  -  -  332 

V.     Wounds  of  the  Pancreas,  -----  338 

1.  Contusion,  ------  338 

2.  Penetrating  Wound  of  Abdomen  with  Protrusion  of  Pan- 

creas,   -------  338 

3.  Gunshot  wounds,  -  341 

VI.     Acute  Pancreatitis,         ------  348 

VII.     Chronic  Interstitial  Pancreatitis,  or  Sclerosis  of  the  Pancreas,  351 

VIII.     Gangrene  of  the  Pancreas,        -----  355 

IX.     Abscess  of  the  Pancreas,     -----  357 

1.  Pathology,   -  -  -  -  -  364 

2.  Symptoms  and  Diagnosis,        -  366 

3.  Prognosis,    -  -  -  -  367 

4.  Treatment,         ------  368 

X.     Haemorrhage  of  the  Pancreas,  ....  370 

1.  Varieties,  ------  371 

a.  Haemorrhagic  Cysts,    -----  371 

b.  Diffuse  Haemorrhage,         ....  373 

2.  Symptoms  and  Diagnosis,  ...  -  377 

3.  Treatment,         ------  378 

XI.     Cysts  of  the  Pancreas,  -  -  -  379 


CONTENTS.  ix. 

PAGE 

XII.     Tumors  of  the  Pancreas,     -----  333 

1.  Hypertrophy,  ------  333 

2.  Sarcoma,  -  -  •  -  -  -  384 

3.  Carcinoma,  -------  385 

4.  Symptoms  and  Diagnosis,        ....  337 

5.  Treatment,  -------  388 

XIII.  Tuberculosis  of  the  Pancreas,         -  390 

XIV.  Lipomatosis  of  the  Pancreas,  -  -  -  -  -    391 
XV.     Lithiasis  of  Pancreatic  Ducts,        -  393 

1.  Symptoms  and  Diagnosis,  -----    395 

2.  Treatment,  --....  395 

XVI.     Conclusions,        -------    397 

An  Expebimental  Contribution   to  Intestinal  Subgeet,  with  Special 

Refebence  to  the  Tbeatment  of  Intestinal  Obstbuction,     -  399 
[Reprinted  from  "Annals  of  Surgery"  by  permission.] 

General  Remarks  on  Experiments,       -  402 

I.     Artificial  Intestinal  Obstruction,    -  404 

1.  Stenosis.       -------  404 

a.  Partial  Enterectomy,          -  404 

b.  Circular  Constriction,               ....  405 

2.  Flexion,               ......  407 

3.  Volvulus,       -------  409 

4.  Invagination,     ------  410 

Permeability  of  the  Ileo-Csecal  Valve,  -  -  415 

II.     Enterectomy,  -...-.  415 

Excision  of  Colon,  -----  419 

Physiological  Exclusion,  ....  421 

III.  Circular  Enterorrhaphy,  -----  424 

Nothnagel's  Test,  -----  429 

Transplantation  of  Omental  Flap,  ...    430 

IV.  Intestinal  Anastomosis.       -----  435 

Directions  for  Preparing  Bone-Plates,      -  -  -  437 

1.  Gastro-Enterostomy,     -----  433 

2.  Jejuno-Ileostomy,   ------  441 

a.     By  Suturing,  -----  441 

3.  Ileo-Colostomy,        ------  447 

a.  By  Implantation,    -----  447 

b.  By  Lateral  Apposition,  -  450 

c.  By  Perforated  Approximation  Discs,        -  453 

4.  Ileo-Rectostomy.      ---...  455 

5.  Colo-Rectostomy,  -----  45(5 


PAGE 

- 

457 

- 

458 

- 

461 

- 

463 

- 

466 

N  THE 

Canal 

X.  CONTENTS. 

V.     Adhesion  Experiments,        - 

1.  Traumatic  Irritation  of  Serous  Surfaces,  - 

2.  Chemical  Irritation  of  Serous  Surfaces, 

3.  Omental  Grafting,  -  -  -  - 

VI.     Conclusions,  ..... 

Rectal  Insufflation  of  Hydbogen  Gas  an  Infallible  Test  ; 
Diagnosis  of  Visceeal  Injuby  of  the  Gasteo-Intestinal 
in  Penetbating  Wounds  of  the  Abdomen,  ...    473 

[Read  before  the  American  Medical  Association,  1888.] 

I.     Permeability  of  the  Ileo-Csecal  Valve  to  Rectal  Insufflation 

of  Air  or  Gas,  .....  476 

1.  Rectal  Insufflation  of  Air,  ....    480 

2.  Inflation  of  Alimentary  Canal  through  Stomach  Tube,        483 

3.  Experiments  to  Determine  the  Degree  of  Force  which 

is    Necessary  to  Overcome  the   Resistance  Offered 

by  the  Ileo-Csecal  Valve,  ....    485 

4.  The  Amount  of  Pressure  Necessary  to  Force  Hydrogen 

Gas  through  the  Entire  Alimentary  Canal  by  Rectal 
Inflation,    -  487 

II.     The  Resistance  of  Different  Portions  of  the    Gastrointes- 
tinal Canal  to  Diastaltic  Force,    -  489 

1.  Stomach,  ...-.-  489 

2.  Small  Intestines,      -  -  -  -  -  -  490 

3.  Colon,     -  -  -  -  490 

III.  Distention  of  Gastro-Intestinal  Canal  by  Rectal  Insufflation 

of  Hydrogen  Gas,  ....  -    491 

IV.  Hydrogen  Gas  is  Innocuous  and  Non-Irritating  when  Brought 

in     Contact    with    Living    Tissues,    and    is    Promptly 
Removed  by  Absorption,  -  -  -  496 

1.  Peritoneal  Cavity,  ...  .    496 

2.  Pleural  Cavity,  -  -  497 

3.  Subcutaneous  Cellular  Tissue,        ....    497 

V.     Rectal  Insufflation  of  Hydrogen  Gas    in   the   Diagnosis   of 

Penetrating  Gunshot  Wounds  of  the  Abdomen,        '  -  497 


ILLUSTRATIONS. 


Fbactdbes  of  the  Neck  of  the  Femur. 

Page. 

1.  Bony  Union  after  Intra-Capsular  Fracture.     Anterior  View,  -       7 

2.  Bony  Union  after  Intra-Capsular  Fracture.     Posterior  View,     -  8 

3.  Bony  Union  after  Intra-Capsular  Fracture.     Vertical  Section  -       9 

4.  Meyer's  Pressure  and  Traction  Curves,  13 

5.  Partial  Fracture  (Koenig),        -            -            -            -            -  -27 

6.  Partial  Fracture  (Koenig),               -----  27 

7.  Posterior  Impaction  of  Femoral  Neck  (Bigelow),        -             -  -     32 

8.  Posterior  Impaction  of  Femoral  Neck.     Transverse  Section  (Bige- 

low),      --------  33 

9.  Bony  Union  after  Fracture.     Anterior  View  (Hutchinson),  -     71 

10.  Bony  Union  after  Fracture.     Posterior  View  (Hutchinson),        -  72 

11.  Bony  Union  after  Fracture.     Vertical  Section  (Hutchinson),  -     73 

12.  Bony    Union    after   Intra-Capsular     Fracture.       Anterior   View 

(Riedinger).  -  -  -  -  -  -  -74 

13.  Bony    Union     after   Intra-Capsular     Fracture.      Posterior  View 

(Riedinger),  -  -  -  -  -  -  -75 

14.  Vertical  Section  showing  Impaction  with  Bony  Union  after  Intra- 

capsular Fracture  (Riedinger),   -  -  -  -  -  76 

15.  Bony  Union  after  Intra-Capsular  Fracture.    Anterior  View  (Gurlt),  77 

16.  Section  through  Neck, showing  Bony  Union  within  Capsule  (Gurlt),  77 

17.  Appearances    of   Head  and  Neck   of  Femur    in    Senile    Coxitis 

(Richardson),         .-  -  -  -  -  -  -     78 

18.  Apparatus  for  Treating  Fractures  of  Neck  of  Femur,     -  -  94 

19.  Apparatus  Applied;  Steel  Point  of  Instrument  Fixed  in  Trochanter 

Major    --------  94 

ClCATBIZATION  OF  BlOOD-VeSSELS  AFTEE  LlGATUEE. 

1.  Double  Ligation  of  Right  Femoral  Artery  of  Sheep,  -  174 

2.  Double  Ligation  of  Subcutaneous  Artery  of  Sheep,  -  -          176 

3.  Double  Ligation  of  Right  Femoral  Artery  of  Sheep,  -  -  176 

4.  Double  Ligation  of  Right  Carotid  Artery  of  Sheep,  -  176 

5.  Double  Ligation  of  Right  Femoral  Artery  of  Sheep,  -  177 

6.  Double  Ligation  of  Right  Femoral  Artery  of  Sheep,  -  177 

7.  Double  Ligation  of  Right  Femoral  Artery  of  Sheep,  -  178 

8.  Double  Ligation  of  Right  Femoral  Artery  of  Goat,  -        178 

9.  Double  Temporary  Ligation  of  Right  Common  Carotid  Artery  of 

Sheep,  -  -  -----         180 


Xll.  ILLUSTRATIONS. 

Page. 

10.  Double  Ligation  of  Right  Jugular  Vein  of  Sheep,     -  -  -  181 

11.  Double  Ligation  of  Right  Jugular  Vein  of  Sheep,  -  -  181 

12.  Double  Ligation  of  Right  Jugular  Vein  of  Sheep,     -  -  -  182 

13.  Double  Ligation  of  Right  Femoral  Vein  of  Sheep,  -  -  182 

14.  Double  Temporary  Ligation  of  Right  Jugular  Vein  of  Goat,  -  182 

15.  Double  Temporary  Ligation  of  Right  Jugular  Vein  of  Sheep,  -  183 

16.  Double  Temporary  Ligation  of   Left  Jugular  Vein  of  Sheep,  -  183 

17.  Microscopical  Appearances  Presented  by  Specimen  from  Experi- 

ment 19.     Transverse  Section  through  Border  of  Artery,         -  192 

18.  Microscopical  Appearances  Presented  by  Specimen  from  Experi- 

ment 43.     Transverse  Section  of  Part  of  Vein  in  Ligated  Por- 
tion,      --------  193 

Stjbgebv  of  the  Panceeas. 

1.  Embryo  of  Chick,  Four  Days  Old,       -  -  -  292 

2.  Embryo  of  Chick,  Five  Days  Old,  -  -  -  -         293 

3.  Larva  of  Frog,  -  -  -  -  -  -  -  -  294 

4.  Complete  Section  of  Pancreas  of  Dog      ...  -  301 

5.  Comminution  of  Pancreas  of  Cat,       -----  305 

6.  Partial  Extirpation  of  Pancreas  of  Dog,  ...  313 

7.  Normal  Microscopical  Appearance  of  Parenchyma  Cells  from  Duo- 

denal Portion  of  Pancreas  of  Dog,    -  -  -  -  317 

8.  Microscopical  Appearance  of  Parenchyma  Cells  in  Isolated  Splenic 

Portion  of  Pancreas  of  Dog,  -  318 

9.  Sclerosis  of  Splenic  End  of  Pancreas  of  Dog,  -  318 

10.  Obliteration  of  Pancreatic  Duct  of  Cat,  by  Elastic  Constriction,      319 

11.  Section  from  Splenic  Portion  of  Pancreas  of  Cat,  showing  Normal 

Parenchyma,    -------  320 

12.  Incomplete  Fatty  Degeneration  from  Duodenal  Portion  of  Gland 

of  Pancreas  of  Cat,  -  -  -  -  -  -  320 

13.  Complete  Fatty  Degeneration  from  Duodenal  Portion  of  Gland  of 

Pancreas  of  Cat,           -             -            -             -             -            -  321 

14.  Obliteration  of  Pancreatic  Duct  of  Cat,  by  Elastic  Constriction,  -  322 

15.  Obliteration  of  Pancreatic  Duct  of  Cat,  by  Elastic  Constriction,  323 

16.  Obliteration  of  Pancreatic  Duct  of  Cat,  by  Elastic  Constriction. 

Posterior  View,  ------  324 

17.  Obliteration  of  Pancreatic  Duct  of  Dog  by  Elastic  Constriction,    -  325 

18.  External  Pancreatic  Fistula  of  Dog,        ...  -  330 

19.  External  Pancreatic  Fistula  of  Dog,  -----  331 

20.  External  Pancreatic  Fistula  of  Dog,  Duodenal  Portion  of  Gland,       331 

21.  Wet   Preparations  of  Portions  of   Spleen,  Pancreas,  Kidney  and 

Cseliac  Axis,  showing  Musket  Ball  Embedded  in  the  Pancreas,    342 

22.  Pancreas,  with  a  Conoidal  Musket  Ball  Embedded  in  its  Head,       -  344 

Tbeatment  of  Intestinal  Obsteuotion. 

Methods  of  Intestinal  Anastomosis,         ...  -  471 

Author's  Modification  of  Jobert's  Suture,      -  -  -  -    471 


EXPERIMENTAL  SURGERY. 


FRACTURES  OF  THE  NECK  OF  THE  FEMUR,  WITH 
SPECIAL  REFERENCE  TO  BONY  UNION  AFTER 
INTRA-CAPSULAR  FRACTURE.1 


I.     Experiments  on  Animals. 

These  experiments  were  undertaken  with  a  view  of  obtaining 
information  concerning  the  following  questions:  1.  What  is  the 
mode  of  repair  after  non-impacted  intracapsular  fracture  of  the 
neck  of  the  femur?  2.  What  becomes  of  a  bone  or  metallic  nail 
when  driven  into  the  neck  of  the  femur  and  retained  permanently? 

3.  What  is  the  effect  of  such  a  nail  upon  the  adjacent  bone  tissue? 

4.  Can  we,  in  cases  of  intra  capsular  fractures  of  the  neck  of  the 
femur,  by  immediate  or  direct  measures,  as  by  nailing  the  fragments 
together,  obtain  such  accurate  coaptation  and  retention  as  to  secure 
union  by  bone  ? 

A  great  many  difficulties  were  encountered  in  performing  these 
experiments,  prominent  among  which  were  shortness  of  the  femoral 
neck,  difficulty  in  carrying  out  the  antiseptic  treatment,  and  in  pro- 
viding additional  means  for  securing  immobility  of  the  fractured 
bone,  and  the  great  danger  to  life  in  using  anaesthetics.  After  I  had 
lost  a  number  of  animals  from  the  administration  of  chloroform  and 
sulphuric  ether,  I  relied  exclusively  on  hypodermic  injections  of 
morphia  for  preventing  pain  during  the  operation.  The  experiments 
were  made  on  cats,  dogs,  and  rabbits,  embracing  in  all  thirty-three 

'Transactions  of  t  lie  American  Surgical  Association,  vol.  1,  1883. 
1 


I  EXPERIMENTAL   SURGERY. 

operations  upon  thirty  animals.  In  the  first  thirteen  operations  the 
capsule  of  the  hip-joint  was  exposed  by  a  small  posterior  incision, 
and  the  neck  was  rendered  more  accessible  by  forcibly  rotating  the 
thigh  inward;  the  bone  was  perforated  a  sufficient  number  of  times 
with  a  small  drill  close  to  the  head,  and  usually  fractured  by  forcible 
abduction  and  rotation  outward  of  the  limb.  The  fracture  usually 
took  place  with  a  distinct  snap,  and  was  followed  by  all  the  charac- 
teristic symptoms  of  fracture  through  the  neck;  preternatural  mobil- 
ity, shortening,  and  crepitus.  The  incision  was  closed  with  catgut 
sutures,  and  the  wound  covered  with  iodoform  and  salicylated  cotton. 
In  all  of  these  cases  the  fractured  bone  was  replaced  as  nearly  as 
possible  in  the  normal  position,  and  a  plaster- of -paris  dressing 
applied,  which  included  the  pelvis  and  both  extremities.  Two  of 
these  animals  died  of  pyaemia,  and  in  not  a  single  instance  out  of 
the  whole  number  could  the  slightest  attempt  at  bony  union  be  found 
at  the  post-mortem  examination.  In  one  instance  (a  young  New- 
foundland dog)  the  hip -joint  presented  evidences  of  severe  inflam- 
mation without  suppuration;  the  head  of  the  femur,  having  necrosed, 
was  found  completely  detached  in  the  acetabulum.  In  some  cases 
ligamentous  union  had  taken  place,  while  in  others  the  fractured 
surfaces  were  covered  with  healthy  granulations.  In  all  the  speci- 
mens the  lower  fragment  had  become  shortened. 

Having  satisfied  myself  that  antiseptic  treatment  could  not  be 
followed  with  sufficient  accuracy  in  these  cases  to  protect  the  animals 
against  infection,  I  determined  to  fracture  the  neck  subcutaneously. 
In  the  next  six  cases,  after  shaving  and  disinfecting  the  hip,  rotating 
the  thigh  inward  and  sliding  the  skin  forward,  I  made  a  puncture 
down  to  the  neck  of  the  femur  from  behind  with  a  narrow  tenotome 
and,  inserting  the  drill  into  the  passage  made,  divided  and  fractured 
the  neck  as  before.  The  retracting  of  the  skin  made  the  operation 
entirely  subcutaneous.  A  plaster-of-paris  dressing  was  applied  in 
the  same  manner  as  in  the  first  series  of  experiments.  No  inflam- 
mation or  febrile  reaction  followed  these  operations,  and  the  post- 
mortem examinations  showed  evidence  of  ligamentous  repair.  In 
the  absence  of  bony  union,  the  functional  result  in  several  cases 
appeared  remarkable.  With  few  exceptions,  all  of  the  fractures  so 
far  produced  were  proved  at  the  post-mortem  examinations  to  be 
purely  intra-capsular. 

In  experiment  No.  21  the  neck  was  fractured  subcutaneously 


FRACTUEE    OF   THE   NECK   OF   THE   FEMUR.  3 

and  no  retaining  dressing  applied.  The  animal  was  killed  live  weeks 
after  the  operation,  and  an  examination  of  the  hip-joint  showed  that 
a  firm  and  short  ligamentous  union  had  taken  place.  After  the  first 
three  weeks  little  or  no  lameness  could  be  detected. 

Having  failed  in  all  these  cases  in  obtaining  union  by  bone,  I 
determined  to  secure  immediate  and  direct  coaptation  by  nailing  the 
fragments  together. 

The  fracture  was  produced  subcutaneously  in  the  same  way  as 
^  in  the  preceding  series  of  cases  and,  after  replacing  the  limb  in  its 
natural  position  and  sliding  the  opening  in  the  skin  to  a  point  cor- 
responding with  the  centre  of  the  base  of  the  femoral  neck,  the  drill 
was  introduced,  and  a  perforation  made  in  the  direction  of  the  centre 
of  the  femoral  head,  and  a  wire-nail  or  bone-peg  of  proper  length 
driven  into  the  opening  made  by  the  drill,  so  that  the  outer  extrem- 
ity of  the  nail  should  not  project  beyond  the  surface  of  the  bone. 

The  first  two  animals  progressed  very  favorably  after  the  oper- 
ation and  appeared  to  suffer  but  little  pain,  but  unfortunately  they 
escaped  before  an  examination  could  be  made  to  ascertain  the 
results. 

Experiment  21.  Young  cat.  Fractured  the  right  femoral  neck  subcuta- 
neously, and  nailed  the  fragments  with  a  bone-nail.  Animal  killed  ten  weeks 
utter  operation.  Neck  of  femur  almost  entirely  absorbed;  capsular  ligament 
thickened;  vertical  section  through  head,  neck,  and  upper  portion  of  shaft 
showed  that  the  head  was  almost  in  contact  with  the  trochanteric  portion  of 
the  femur;  posterior  portion  of  neck  showed  line  of  fracture  near  the  head, 
and  fractured  surfaces  in  close  contact,  but  movable  upon  each  other;  ante- 
rior portion  firmly  united  by  a  dense  compact  callus,  the  upper  fragment 
apparently  impacted  into  the  lower;  no  trace  of  the  bone-peg  could  be  found. 
The  perforation  in  the  trochanter  major  could  be  followed  to  a  distance  of 
about  2  mm.  In  this  specimen  the  lower  fragment  appeared  to  have 
become  almost  completely  absorbed,  as  the  upper  fragment  remained  un- 
changed, and  appeared  to  be  almost  in  direct  contact  with  the  trochanteric 
portion  of  the  femur.     Ligamentum  teres  normal. 

Experiment  25.  Adult  cat;  subcutaneous  fracture  of  neck  of  right  femur; 
direct  transfixion  of  fragments  with  wire-nail.  Animal  killed  eighteen  weeks 
after  operation.  Fracture  within  capsule  close  to  the  head;  fragments  in 
close  contact,  slightly  movable  upon  each  other,  but  united  by  a  very  shorl 
ligament.  N'ail  had  slipped  outward,  and  projected  from  the  trochanteric 
surface  about  one  third  of  an  inch,  and  could  he  felt  as  a  sharp  point  imme- 
diately under  the  skin.  The  projecting  portion  of  the  nail  was  invested  by  a 
firm,  dense,  fibrous  capsule,  while  the  implanted  portion  was  firmly  and 
immovably  fixed  in  the  bone.     Vertical  section  through  the  head,  neck,  and 


4  EXPERIMENTAL  SURGERY. 

trochanteric  portion  showed  that  almost  the  entire  neck  had  disappeared  by 
interstitial  absorption,  the  upper  fragment  being  almost  in  contact  with  the 
trochanteric  portion.  The  trochanteric  portion  had  almost  entirely  lost  its 
cancellated  structure,  its  interior  being  filled  with  compact  tissue;  this  change 
was  conspicuous  more  particularly  in  that  portion  traversed  by  the  nail. 
Capsular  ligament  thickened;  ligamentum  teres  normal. 

Experiment  26.  Adult,  large  Maltese  cat;  subcutaneous  fracture  of  right 
femoral  neck;  direct  coaptation  of  fragments  with  wire-nail.  Animal  killed 
ten  weeks  after  operation.  Neck  of  femur  shortened;  capsular  ligament 
thickened;  ligamentum  teres  normal;  vertical  section  through  the  upper  por- 
tion of  the  femur  showed  line  of  fracture  within  capsule,  with  impaction  of 
upper  fragment  into  lower;  fragments  movable  upon  each  other,  but  broken 
surfaces  in  immediate  contact.  A  new  compact  layer  of  bone  was  formed  on 
the  outer  surface  of  the  compacta  in  the  region  of  the  lesser  trochanter.  Nail 
firmly  imbedded  in  bone,  outer  extremity  on  a  level  with  compact  layer  of 
trochanter  major;  it  was  seen  to  traverse  the  trochanteric  portion  in  a  back- 
ward direction,  entering  the  cavity  of  the  hip-joint,  and  being  in  close  contact 
with  the  posterior  surface  of  the  femoral  neck,  its  sharp  point  being  on  a  level 
with  the  highest  point  of  the  head.  No  inflammation  in  the  hip-joint.  During 
life  the  function  of  the  joint  appeared  to  be  perfect.  As  the  point  of  the  nail 
was  firmly  fixed  in  the  capsular  ligament,  and  impaction  had  taken  place 
during  the  nailing  process,  immobility  was  tolerably  well  attained,  and  there 
is  every  reason  to  believe  that  bony  union  would  ultimately  have  taken  place. 

Experiment  27.  Adult  Maltese  cat;  subcutaneous  fracture  of  left  femoral 
neck;  fixation  of  fragments  by  means  of  bone-peg  made  from  compacta  of 
tibia  of  an  ox.  Animal  killed  fourteen  weeks  after  operation.  Neck  of  femur 
only  slightly  shortened;  capsular  ligament  nearly  normal;  ligamentum  teres 
normal;  vertical  section  showed  a  slight  curve  in  the  upper  portion  of  the 
neck,  the  head  being  slightly  depressed.  Perfect  and  complete  bony  union, 
the  spongiosa  being  restored  nearly  to  its  normal  condition.  Bone-peg  had 
disappeared  completely. 

Experiment  28.  Old  Maltese  cat;  subcutaneous  fracture  of  left  femoral 
neck;  direct  adjustment  of  fragments  by  bone-peg.  Cat  died  of  fatty  degen- 
eration of  liver  and  kidneys  five  weeks  after  operation.  Vertical  section 
through  upper  portion  of  femur  revealed  line  of  fracture  partly  within  and 
partly  without  the  capsule;  no  union;  fragments  in  good  apposition;  outer 
extremity  of  bone-nail  beneath  the  compacta;  direction  of  nail  downward  and 
inward,  the  point  terminating  a  little  beyond  the  line  of  fracture  in  the  lower 
portion  of  the  neck.  The  saw  had  divided  the  nail  obliquely  at  the  juncture 
of  the  outer  with  the  middle  third.     No  evidences  of  inflammation  or  repair. 

Experiment  29.  Adult  cat;  fractured  neck  of  left  femur  subcutaneously, 
and  used  bone-peg  for  nailing  fragments  together.  Animal  died  of  pyasmia 
twelve  days  after  operation.  Hip-joint  filled  with  pus;  fracture  intra-capsular; 
outer  extremity  of  nail  on  a  level  with  compacta,  its  point  in  the  cavity  of 
the  joint  on  a  level  with  the  foveola  of  the  head.     A  piece  of  the  posterior 


FRACTURE   OF  THE   NECK   OF   THE   FEMUR.  0 

portion  of  the  head  was  split  off,  an  accident  which  occurred  either  by  the 
drill  or  driving  in  of  the  nail. 

Experiment  30.  Adult  cat;  subcutaneous  fracture  of  right  femoral  neck; 
direct  transfixion  of  fragments  by  wire-nail.  Animal  died  of  pneumonia  four 
weeks  after  operation.  No  inflammation  of  joint;  fracture  intra-capsular; 
fragments  slightly  separated  but  well  transfixed  by  nail;  no  callus. 

Experiment  31.  Young*  cat;  subcutaneous  fracture  of  neck  of  right 
femur;  direct  fixation  of  fragments  with  bone-peg.  Animal  killed  four  months 
after  operation.  During  life  function  of  the  joint  was  perfect;  vertical  section 
through  the  head,  neck,  and  upper  portion  of  the  shaft,  showed  that  the  line 
of  fracture  must  have  been  entirely  within  the  capsule,  as  no  thickening  of 
bone  or  ligament  could  be  seen;  capsular  ligament  normal.  Accurate  meas- 
urement showed  only  an  appreciable  shortening  of  neck;  compact  tissue  with- 
in neck  more  abundant  than  in  the  opposite  bone.  Spongiosa  restored  to 
nearly  its  natural  perfection.      No  trace  of  track  of  perforation  or  bone-nail. 

Iii  no  case  did  I  feel  crepitation  more  perfectly  than  in  this  case, 
and  the  sudden  giving  way  of  the  bone  the  moment  it  was  fractured 
was  well-marked,  and  heard  by  several  witnesses.  As  the  post- 
mortem examination  showed  a  most  perfect  restoration  of  the  conti- 
nuity of  the  bone,  I  am  convinced  that  this  case  represents  a  typical 
and  perfect  recovery  of  union  by  bone  after  intra-capsular  fracture 
of  the  neck  of  the  femur. 

In  all  cases,  twenty-one  in  number,  where  no  direct  means  of 
fixation  were  used,  there  was  not  the  slightest  evidence  of  bony  union, 
the  best  result  attained  being  a  short  ligamentous  band.  In  experi- 
ment No.  '21,  no  retention  dressing  was  applied,  and  the  result  was 
equally  good,  if  not  better,  than  in  the  cases  where  the  plaster-of- 
paris  dressing  was  used. 

In  all  of  these  cases  the  tendency  to  shortening  was  not  as  well 
marked  as  in  man,  while  eversion  occurred  seldom  and  only  to  a 
slight  degree.  The  weight  of  the  limb  evidently  counteracted  mus- 
cular action,  while  the  conditions  which  produce  eversion  in  man  were 
absent  in  animals.  The  results  obtained  by  immediate  transfixion  of 
the  fragments  stand  in  direct  contrast  to  those  treated  by  external 
fixation.  Bony  union,  or  union  by  short  ligament,  was  the  rule,  non- 
union the  exception. 

These  experiments  would  also  tend  to  prove  that  aseptic  metallic 
nails,  when  implanted  subcutaneously  into  living  bone,  remain  firmly 
in  its  substance  for  an  indefinite  period  of  time  without  giving  rise 
to  suppuration.  And  from  one  of  the  experiments  it  will  be  seen 
thai  the  point  of  the  nail  was  within  the  cavity  of  the  joint  formanj 


6  EXPERIMENTAL   SURGERY. 

weeks  without  materially  interfering  with  the  normal  function  of  the 
joint,  or  producing  more  than  a  slight  synovitis. 

Iron-  and  bone-nails,  if  driven  into  living  bone,  produce  osteo- 
plastic inflammation,  and  are,  on  this  account,  not  only  useful  in  the 
treatment  of  pseud-arthrosis,  but  are  equally  beneficial  in  accelerat- 
ing the  reparative  process  in  recent  fractures.  Bone-nails  are  com- 
pletely absorbed,  the  time  required  for  absorption  to  take  place 
depending  upon  the  vascularity  of  the  tissues  which  are  in  imme- 
diate contact  with  the  nail. 

According  to  Gurlt,  the  time  required  for  bony  union  to  take 
place  is  proportionate  to  the  diameter  of  the  fractured  bone,  being 
much  shorter  in  case  of  slender  bones  than  in  those  of  greater  diam- 
eter. It  appears  that  in  cats  the  shortest  time  for  the  slender  neck  of 
the  femur  to  unite  by  bone  is  at  least  two  months ;  hence  in  man  the 
time  required  for  bony  consolidation  of  fracture  of  the  femoral  neck 
must  be  at  least  from  one  hundred  to  one  hundred  and  twenty  days. 
As  in  two  of  the  specimens,  well-marked  impaction  occurred  during 
the  nailing  process,  the  question  arises:  Could  not  the  same  desirable 
conditions  be  obtained  in  man  by  using  sufficient  lateral  force  at  the 
time  direct  coaptation  is  attempted?  In  other  words:  Would  it  not 
be  prudent  to  use  sufficient  force  to  produce  artificial  impaction  ? 

In  nearly  all  the  specimens  the  upper  fragment  underwent  but 
little  change,  while  the  lower  fragment  always,  without  exception, 
suffered  a  diminution  in  length  from  osteo-porotic  inflammation  and 
interstitial  absorption. 

Interstitial  absorption,  as  the  consequence  of  inflammatory 
osteo-porosis,  takes  place  to  a  greater  or  less  extent  in  every  case  of 
fracture  through  the  femoral  neck,  and  precedes  and  accompanies 
the  reparative  process.  In  all  cases  of  bony  union  the  posterior 
attachment  of  the  cervical  portion  of  the  capsular  ligament  was  dis- 
placed outward,  an  occurrence  which  can  only  be  explained  satisfac- 
torily by  assuming  that  during  the  osteoporotic  inflammation,  the 
periosteal  investment  of  the  femoral  neck  is  loosened  and  trans- 
planted toward  the  femoral  shaft,  carrying  with  it  the  femoral  inser- 
tion of  the  capsular  ligament.  These  experiments  also  illustrate  the 
difficulty  of  transfixing  the  upper  fragment  in  the  process  of  nailing; 
a  circumstance  largely  due  to  the  diminutive  size  of  the  bone,  the 
incomplete  anaesthesia,  and  the  want  of  fixation  of  the  parts  in  their 
relative  normal  positions  previous  to  the  operation. 


BONY   UNION  AFTER   IMPACTED   FRACTURE.  7 

II.     Bony  Union  after  Impacted  Intra-Capsular  Fracture 
of  the  Neck  of  the  Femur. 

At  a  previous  meeting  of  the  American  Surgical  Association,1 
I  presented  a  specimen  of  bony  union  after  an  intra-capsular 
fracture  of  the  neck  of  the  femur,  and  gave  a  full  description  of  the 
case  and  specimen.  In  the  discussion  which  followed,  it  became 
not  only  evident  that,  in  the  opinion  of  the  speakers,  the  specimen 
was  not  what  I  had  claimed  for  it.  but  that  such  a  favorable  occur- 


S: 


Qt* 


1 


Fig.  1.     Bony  Union  after  Intra-Capsular  Fracture.     (Anterior  view.) 
a.     Line  of  Fracture.     6.     Capsular  Ligament. 

rence  was  aoi  possible,  and  that  a  well -authenticated  case  had 
never  been  observed.  These  criticisms  induced  me  to  look  up  the 
literature  of  the  subject  with  care  and  impartiality,  and  to  resort  to 
experiment  to  verify  my  posit  ion. 

Case.    The  patient  was  a  female,  aged  seventy-five  years,  and  was  under 
my  observation  at  the  Milwaukee  Hospital.     She  was  in  good  health  at  the 

1  Transactions  American  Surgical  Association.  1882. 


EXPERIMENTAL   SURGERY. 


time  of  the  accident,  hence  there  can  be  no  possibility  that  the  extensive 
changes  in  the  neck  of  the  femur  were  the  result  of  senile  coxitis  or  interstitial 
absorption.  The  fracture  was  produced  by  direct  violence  by  a  fall  upon  the 
greater  trochanter.  Fractures  of  the  neck  produced  in  this  manner  are  very 
apt  to  be  impacted.  Loss  of  function  was  complete  immediately  after  the 
injury,  and  remained  so  for  several  months.  The  patient  suffered  great 
pain  in  the  groin  and  the  region  of  the  trochanter  minor,  a  symptom  which  is 
always  indicative  of  injury  within  the  capsular  ligament.  For  the  purpose  of 
excluding   asymmetry  of  the  bones,  all  the   long    bones  of   both   legs  were 


a  .4 


Fig.  2.     Bony  Union  after  Intra-Capsular  Fracture.    (Posterior  view.) 
a.     Capsular  Ligament. 

measured  separately,  and  on  comparing  the  measurements  the  injured  limb 
was  found  shortened  half  an  inch.  The  limb  was  strongly  everted.  Gentle 
traction  had  no  effect  on  the  length  of  the  limb.  On  comparing  the  move- 
ments of  the  trochanter  major  on  both  sides  by  rotating  the  limbs,  it  was 
found  that  the  neck  of  the  femur  on  the  affected  side  was  perceptibly  shorter. 
No  crepitation  could  be  felt.  As  the  impaction  appeared  to  be  firm  no  treat- 
ment was  employed,  except  rest  in  bed  on  a  smooth  even  mattress,  the  limb 
being  supported  on  each  side  with  sand-bags.  In  this  position  the  patient 
remained  for  three  months;  at  the  expiration  of  this  time  she  was  allowed  to 
walk  on  crutches.      After  the  third  week  the  shortening  gradually  increased 


BONY    UNION  AFTER   IMPACTED    FRACTURE. 


9 


until  it  reached  an  inch  and  a  half,  when  the  treatment  was  suspended.  The 
secondary  shortening  I  attributed  to  inflammatory  osteo-porosis  and  inter- 
stitial absorption  in  the  lower  fragment.  The  patient  eventually  was  able  to 
walk  quite  well  with  the  aid  of  a  cane.  Two  years  after  the  accident  she  died 
of  pneumonia.     The  post-mortem  appearances  were  as  follows: 

The  capsule  of  the  joint,  especially  the  upper  portion,  was  thickened  and 
firm,  and  bridges  of  fibrous  bands  connected  the  line  of  fracture  with  the 
anterior   portion  of  the  ligament.     On  the  anterior  surface  of  the  neck  the 


Fio.  3.     Bony  Union  after  Intra-Capsular  Fracture.     (Vertical  section.) 
a.     Compact  Plate  of  Bone. 

direction  of  the  fracture  could  be  clearly  traced  from  below  upward,  and  from 
within  outward,  but  it  did  not  extend  beyond  the  insertion  of  the  capsular 
ligament.  The  line  of  fracture  was  elevated,  and  presented  a  serrated 
appearance.  Posteriorly  the  bead  of  the  bone  was  in  close  proximity  to  (In- 
posterior  intertrochanteric  ridge.  A  Blight  depression  on  the  articular 
cartilage  marked  the  point  of  contaci  with  the  inner  surface  of  the  capsular 
ligament.       Impaction    had    evidently    taken     place    at    the    expense    of    the 


10  EXPERIMENTAL   SURGERY. 

posterior  compact  portion  of  the  neck.  A  portion  of  Adams'  arch,  which  had 
been  implanted  into  the  lower  fragment,  could  be  distinctly  seen  in  the 
spongiosa,  on  making  a  vertical  section  (Figs.  1,  2,  3). 

A  vertical  section  through  the  neck,  head,  and  trochanter  revealed  a  white 
line  of  very  compact  bone  traversing  the  cancellous  tissue  of  the  neck  near 
the  shaft  in  an  oblique  direction,  corresponding  to  the  line  of  fracture  on  the 
anterior  surface  of  the  neck.  The  anterior  half  of  the  specimen  was  submitted 
to  the  boiling  test  without  affecting  the  union  of  the  fragments,  hence  there 
could  be  no  doubt  as  to  the  union  by  bone.  The  bone  outside  of  the  capsular 
ligament  presented  no  sign  of  callus  or  any  other  evidences  of  injury  or 
disease. 

III.    Anatomy  of  the  Neck  of  the  Femur. 

The  neck  of  the  femur  is  that  portion  of  the  upper  extremity 
of  the  bone  located  between  the  head  and  trochanters.  It  is  a 
continuation  of  the  shaft,  and  springs  from  an  oblong  rhomboidal 
surface  from  the  inner  side  of  the  trochanteric  region,  and  is  directed 
obliquely  upward,  inward,  and  a  little  forward.  Its  base  is  limited 
anteriorly  and  posteriorly  by  the  inter-trochanteric  lines;  above  and 
behind  it  reaches  the  summit  of  the  greater  trochanter,  while  below 
and  in  front  it  extends  to  the  upper  margin  of  the  lesser  trochanter. 
In  animals  the  neck  of  the  femur  is  exceedingly  short,  and  usually 
set  almost  at  a  right  angle  with  the  shaft.  The  great  length  and 
obliquity  of  the  neck  is  peculiar  to  man.  It  is  this  which  gives 
elasticity,  freedom  and  grace  to  the  motions  of  the  body,  but  at  the 
same  time  its  great  length  increases  the  liability  to  fracture.  The 
decided  inclination  of  the  neck  forward  naturally  turns  the  lower 
limb  a  little  outward,  and  constitutes  an  important  determining 
element  in  the  production  of  posterior  impaction  and  eversion  of  the 
limb  in  case  of  fracture. 

The  length  and  obliquity  of  the  neck  vary  at  different  ages  and 
under  different  circumstances,  in  harmony  with  the  requirements  of 
age  or  conditions.  In  children  it  is  very  oblique,  short,  and  slender, 
and  the  bony  prominences  about  the  hip  are  not  well  defined.  As 
old  age  advances,  the  neck  in  some  instances  undergoes  remarkable 
changes  in  structure,  contour,  and  direction;  its  obliquity  in  many 
instances  diminishes  to  such  an  extent  that  the  head  descends  below 
the  level  of  the  superior  border  of  the  greater  trochanter,  and  at  the 
same  time  its  length  is  greatly  diminished.  During  adult  life,  when 
the  femur  represents  the  most  perfect  degree  of  development  and 
maximum  power  of  resistance,  the  neck  forms  an  obtuse  angle  with 


ANATOMY   OF   THE   NECK   OF   THE   FEMUR.  11 

the  shaft  varying  in  degree  from  120°  to  130°. 1  Viewed  from  the 
front  or  from  behind,  it  is  seen  that  the  neck  is  widest  at  its  base  or 
trochanteric  portion,  gradually  becoming  narrower  until  its  most 
contracted  part  is  reached  near  the  head,  when  it  abruptly  expands 
into  the  corona  of  the  head.  The  posterior  surface  is  smooth  for 
the  play  of  muscles,  especially  the  obturator  externus ;  convex  in  the 
vertical  and  concave  in  the  longitudinal  direction. 

The  anterior  surface  is  rough,  flat  from  above  downward,  and 
slightly  concave  from  without  inward.  On  account  of  the  direction 
of  the  neck  forward  the  anterior  surface  is  somewhat  shorter  than 
the  posterior.  According  to  Heppner  this  difference  amounts  to  two 
or  two  and  a  half  lines. 2  The  under  surface  is  smooth,  and  forms 
with  the  inner  side  of  the  shaft  a  well-marked  curve  or  arch  nearly 
three  inches  in  length ;  the  upper  surface  is  rough  and  only  half  the 
length  of  the  lower. 

The  thin  compact  layer  of  bone  on  the  anterior  and  upper 
surface  is  perforated  by  numerous  foramina  for  the  passage  of 
nutrient  vessels.  Seen  from  above,  the  neck  appears  much  narrower 
than  from,  an  anterior  or  posterior  view.  The  proportion  of  the 
diameter  of  the  neck  from  above  downwards,  and  from  before  back- 
wards, at  the  trochanteric  portion,  is  as  two  to  one. 

From  the  general  anatomical  description,  it  becomes  apparent 
that  the  neck  of  the  femur  is  constructed  strictly  on  purely  mechan- 
ical principles,  in  order  to  resist  the  greatest  amount  of  vertical 
pressure;  but  this  becomes  more  evident  if  we  study  the  inner 
architecture  of  the  upper  portion  of  the  femur,  and  more  particularly 
the  neck.  On  making  a  vertical  section  through  the  head,  neck,  and 
upper  part  of  the  shaft  of  the  femur,  it  may  be  seen  that  the  thick 
compact  layer  of  the  shaft,  as  it  approaches  the  trochanteric  region, 
gives  off  from  its  inner  surface  cancelli  at  regular  intervals,  which 
build  up  the  interior  or  spongy  tissue  of  the  bone.  As  the  spongy 
tissue  is  formed  at  the  expense  of  the  compact  layer,  the  latter 
gradually  becomes  thinner  as  it.  approaches  the  head,  which  it 
supplies  with  a  delicate  layer  of  uniform  thickness. 

The  most  important    part   of   the  cortical  layer  in  relation  to 

1  Fr.  Merkel,  Betrachtungen  ttber  dasoa  femur.   Virohow's  Archie  E.  Pathol. 
Anat.     Band  60,  Seft.  II. 

2  C.   L.   Heppner,    Beobachtungen    n.   Untersuclmngeri    iiber    eingekeilte 
Schenkelhalsbrneche.     Med.  Jahrb.    Band  XVIII,  p.  106. 


12  EXPERIMENTAL   SURGERY. 

fractures  of  the  neck,  is  the  lower  and  inner  portion,  which,  from  the 
support  it  gives  to  the  head  and  neck,  has  been  called  the  Adams 
arch,  or  femoral  brace.  It  is  a  continuation  of  the  cortical  layer  of 
the  inner  portion  of  the  shaft,  preserving  its  thickness  and  strength 
to  a  level  with  the  upper  margin  of  the  trochanter  minor,  where  it 
is  gradually  broken  up  into  spongy  tissue,  until  at  the  corona  it  is 
lost  in  the  thin  cortical  layer  surrounding  the  head.  The  trochanter 
major  is  surrounded  by  a  thin  layer  of  compact  tissue.  Transverse 
sections  made  through  the  neck  at  different  depths  show  that  while 
the  anterior  and  posterior  layers  are  of  the  same  thickness  in  the 
upper  part  of  the  neck,  the  posterior  wall  gradually  loses  in  thick- 
ness, until  near  the  lower  surface  it  is  reduced  to  the  thinness  of 
paper,  while  the  anterior  wall  becomes  of  great  thickness  and 
strength. '  The  direction  of  the  neck,  the  concavity  of  the  posterior 
surface,  and  the  thinness  of  the  posterior  compact  wall  as  compared 
with  the  anterior,  afford  abundant  and  satisfactory  explanations 
concerning  the  frequency  of  posterior  impaction  in  fractures  of  the 
neck,  and  outward  rotation  of  the  limb  in  the  non-impacted  form. 

Of  great  interest  to  the  surgeon  is  the  arrangement  of  the 
cancelli  of  the  spongy  tissue  in  the  upper  part  of  the  femur.  It  is 
true  that  some  of  the  peculiarities  of  the  structure  of  the  spongiosa 
in  this  locality  were  known  to  surgeons  for  a  long  time,  still  the 
credit  is  due  to  H.  Meyer  of  having  first,  in  1867,  called  attention 
to  the  regularity  of  its  construction,  and  out  of  this  deduced  distinct 
and  positive  laws  governing  its  mechanical  construction.2 

He  describes  three  distinct  systems  of  cancelli  which  traverse 
the  neck  in  different  directions.  The  first  begins  on  a  level  with  the 
lesser  trochanter,  and  reaches  in  parallel  curves  the  lower  segment 
of  the  head  of  the  femur.  The  second  system  commences  on  the 
opposite  side  on  the  same  level,  and  traverses  towards  the  outer  side 
of  the  trochanter  major,  and  in  such  a  way  that  the  points  of  inter- 
section of  the  curves  form  a  series  of  arches.  The  third  system, 
which  springs  from  the  commencement  of  the  femoral  brace,  and 
extends  to  the  upper  and  inner  circumference  of  the  head  of  the 
femur,  is  the  strongest,  and  transfers  the  weight  of  the  body  at  once 

1  H.  J.  Bigelow,  M.  D.,  The  True   Neck  of    the  Femur,  its  Structure  and 
Pathology.     Boston  Med.  and  Surg.  Journ.,  Jan.  7,  1875. 

2  H.  Meyer,  Die  Architectur  der  Spongiosa,  Archiv  f.  Anatomie,  von  Reich- 
ert  und  Du  Bois-Reymond,  1867,  p.  624. 


ANATOMY   OF   THE   NECK   OF  THE   FEMUR. 


13 


upon  the  fehioral  brace  on  the  inner  and  lower  side  of  the  neck. 
According  to  Meyer's  description  and  drawings,  a  triangle  exists 
between  the  curves  of  the  rirst  and  second  systems,  the  apex  of 
which  corresponds  to  the  base  of  the  neck.  This  triangular  space 
is  occupied  by  an  irregular  network  of  cancellated  tissue,  or  by 
curves  from  the  second  or  third  system.     This  space,  however,  does 


Fig.  4.     Meyer's  Pressure  and  Traction  Curves.     (Meyer.) 

not  exist  in  all  specimens,  but  is  usually  present  in  the  bones  of 
aged  people,  where  the  spongiosa  has  undergone  rarefaction. 

In  specimens  from  adults  the  interior  of  the  bone  is  tilled  with 
arches  from  the  inner  and  outer  compact  layers  for  some  distance 
below  the  point  indicated  by  Meyer.  In  another  paper1  Meyer 
dwells  at  length  on  the  mechanical  function  of  these  curves,  wThich 
he  calls  pressure  and  traction  curves.  It  seems  as  though  the  com- 
pact layer  is  gradually  lost  in  the  spongiosa.  This  is  well  seen  in  a 
horizontal  section  through  the  long  bones,  more  especially  of  the 
lower  extremity.     The  lamelhe  are  so  arranged  as  to  correspond  to 

1  Die  Statik  u.  Mechanik  dee  mensohliohes  Knoohengerftstes,  L878. 


14  EXPERIMENTAL   SURGERY. 

pressure  and  traction  curves,  a  construction  by  which  the  least  possi- 
ble amount  of  bone  tissue  can  resist  the  greatest  amount  of  force. 
The  spaces  between  these  curves  are  filled  with  loose  cancellated 
tissue,  which  does  not  add  materially  to  the  strength  of  the  bone, 
but  serves  more  the  purpose  of  forming  a  framework  for  the  medul- 
lary tissue.  The  spongiosa  appears,  therefore,  as  the  primary 
typical  structure  of  bone,  and  the  compact  tissue  as  an  accidental 
modification  of  the  spongiosa  constructed  by  local  concentration  of 
resistance  curves. 

Heppner  divides  the  cancelli  of  the  spongiosa  into  two  strong 
and  two  less  dense  portions.  Among  the  first  he  includes  the  fibres 
connecting  the  neck  of  the  femur  with  the  femoral  brace,  and  from 
the  other  side  extending  to  the  base  of  the  femoral  neck.  To  the 
second  portion  belong  the  fibres  in  the  space  between  the  first  two 
portions  and  those  of  the  trochanter  major. 

About  the  same  time  that  Meyer  was  investigating  this  subject, 
Dr.  J.  H.  Packard  published  a  very  interesting  paper  on  "Fractures 
of  the  Neck  of  the  Femur,"1  in  which  he  called  attention  to  the 
architecture  of  the  interior  of  the  neck  of  the  femur,  and  accurately 
described  and  delineated  the  arching  fibres  passing  from  the  femoral 
brace  to  the  upper  segment  of  the  head  of  the  femur.  He  says:  "A 
careful  examination  of  vertical  sections  of  the  head  and  neck  of  "the 
femur  shows,  as  several  writers  have  pointed  out,  that  a  number  of 
the  cancellous  columns,  beginning  at  the  upper  end  of  the  inner  wall 
of  the  shaft  of  the  bone,  diverge  upward  to  the  concavity  of  the  thin 
articular  lamella  of  compact  substances  of  the  head,  so  as  to  receive 
the  weight  of  the  body  upon  their  extremities.  Another  series  of 
columns  are  found  to  run  outward  from  the  same  point,  and  from  a 
line  running  upward  from  it,  to  meet  other  columns  running  up 
inward  from  the  outer  wall  of  the  shaft;  and  these  two  sets  of 
columns  form  a  series  of  groined  arches  culminating  at  the  upper 
wall  of  the  neck  of  the  bone,  a  little  to  the  inner  side  of  the  greater 
trochanter. 

"By  this  arrangement  the  shifting  of  the  weight  towards  the 
outer  or  upper  portion  of  the  head  of  the  bone  is  provided  for,  the 
pressure  coming  in  greater  degree  on  the  outer  wall  of  the  shaft,  the 
inner  wall,  however,  receiving  its  share  through  the  inner  columns 

1  On  some  Points  relating  to  Fractures  of  the  Neck  of  the  Femur,  by  John 
H.  Packard,  M.D.,  Amer.  Journ.  of  Med.  Sciences,  Oct.,  1867,  p.  379. 


ANATOMY   OF   THE   NECK   OF  THE   FEMUR.  15 

of  the  arches.  The  remainder  of  the  cancelli  run  in  various  direc- 
tions, not  capriciously  or  at  random,  but  so  as  to  afford  in  the 
aggregate  a  very  strong  support  to  the  solid  wall  of  the  bone. 
Sometimes  it  may  be  clearly  seen  that  they  are  so  placed  as  to  run 
as  nearly  as  possible  in  the  line  of  muscular  traction;  an  arrange  - 
ment,  the  mechanical  advantage  of  which  must  be  at  once  evident." 

In  1870,  Julius  Wolff '  published  the  result  of  his  studies  of  the 
spongiosa,  which  he  considered  as  standing  in  the  closest  relation  to 
the  static  and  dynamic  forces  of  the  bones.  In  his  researches  he 
made  use  of  the  mathematical  calculations  of  Culmann,  showing 
that  interior  braces  intended  to  aid  in  supporting  a  weight  upon  the 
end  of  a  cylinder,  curved  like  the  femur,  or  like  a  crane  or  derrick, 
should  be  placed,  in  order  to  act  to  advantage,  precisely  where  the 
trabecule  of  the  spongy  tissue  of  this  bone  actually  exist.  "Nature," 
says  Wolff,  "has  built  the  spongy  bones  as  an  engineer  would  con- 
struct a  truss  bridge,  mathematically." 

A  compact  plate  of  bone  (Schenkelsporn,  septum)  is  usually 
found  imbedded  in  the  cancellous  tissue  of  the  neck,  and  to  it  an 
important  function  has  been  assigned  by  Merkel  and  Bigelow. 
Merkel 2  described  a  structure  in  the  interior  of  the  neck  of  the  femur 
which  he  called  "Schenkelsporn."  It  consists  of  a  wedge-shaped 
solid  projection  of  the  cortical  layer,  which  springs  from  its  inner 
surface  on  a  level  with  the  trochanter  minor  towards  the  median 
line,  and  penetrates  into  the  interior  of  the  spongiosa  to  the  depth 
of  1  cm.,  and  is  lost  immediately  under  the  head  of  the  femur  on 
the  anterior  surface  of  the  neck.  It  is  not  found  in  the  foetus,  is 
fully  developed  in  the  adult,  and  again  disappears  completely  during 
old  age. 

Bigelow,  after  describing  the  necessary  manipulations  for 
exposing  it.  says:  "The  septum  will  then  be  distinctly  seen,  as  a 
thin  dense  plate  of  bone  continuous  with  the  back  of  the  neck,  and 
reinforcing  it,  plunging  beneath  the  intertrochanteric  ridge  in  an 
endeavor  to  reach  the  opposite  and  outer  side  of  the  shaft.  At  its 
lower  extremity  it  curves  a  little  forward,  so  as  to  take  its  origin, 
when  on  a   level  with,  from  the  centre,  instead  of  the  back,  of  the 

1  Julius  Wolff,  Ueber  die  innere  Architectur  der  Knochen  und  ihre  Bedeu- 
tuii<,'  fur  die  Frage  von  Knoohenwachsthum.  Archiv  f.  Path.  Anat.  u.  Phys. 
Band  50. 

2  Der  Schenkelsporn.     Centralbl.  f.  d.  Med.  Wissensch.     No.  27,  1873. 


16  EXPERIMENTAL  SURGERY. 

cylindrical  cavity ;  a  disposition  easily  seen  in  a  transverse  section  of 
the  shaft  just  above  the  trochanter  minor.  Or  it  may  be  said  that 
the  posterior  wall  of  the  neck  forks  before  reaching  the  inter-tx-o- 
chanteric  line,  one  layer  being  seen  upon  the  surface,  while  the  other 
dives  beneath  the  inter-trochanteric  ridge  in  a  vain  attempt  to  reach 
the  outer  wall  of  the  shaft.  If  these  views  be  correct,  the  inter- 
trochanteric ridge  is  simply  a  buttress  erected  for  the  insertion  of 
muscles  upon  and  over  the  true  neck,  by  the  impaction  of  which  it 
is  in  fact  often  split  off  and  detached  in  a  mass;  the  force  exerted 
by  the  true  neck,  though  slight,  being  nevertheless  an  effort  to  resist 
such  impaction." 

The  importance  of  this  septum,  when  in  a  perfect  state,  becomes 
evident,  as  the  same  author  continues:  "The  true  neck  is  often,  at 
best,  but  an  ineffectual  attempt  to  bridge  the  interval  beneath  the 
trochanters,  as  seen  in  Merkel's  figures,  while,  in  the  latter  half  of 
life,  it  degenerates  into  papery  plates,  radiating  downward  from  a 
point  near  the  lesser  trochanter.  Weakened  in  this  way,  both  by  its 
own  tenuity  and  by  its  own  slender  union  to  the  trochanteric  ridge, 
the  true  neck  has  great  practical  interest  for  the  surgeon.  Even  the 
adult  femur  is  generally  defective  in  construction  at  this  point;  and 
here  occurs  the  most  common  form  of  fracture,  namely,  the  posterior 
impacted  fracture  of  the  base  of  the  neck." 

Bigelow  looks  upon  the  septum  as  a  continuation  of  the  "True 
Neck,"  while  Merkel  has  described  the  same  structure  as  a  projection 
of  a  portion  of  the  posterior  and  inner  compact  wall  into  the  spong- 
iosa;  hence,  he  has  called  it  "  Calcar  femoral"  or  "  Schenkelsporn." 
The  relation  of  the  septum  to  the  trochanter  minor  is  such  as  to 
isolate  its  spongy  tissue,  and  on  that  account  Wolff  alludes  to  it  as 
"the  compact  tissue  upon  which  the  trochanter  minor  rests."  The 
importance  of  this  structure  in  preventing  and  determining  the  loca- 
tion of  fractures  has  undoubtedly  been  over-estimated.  It  is  absent 
in  children,  and  is  subject  to  the  same  degenerative  changes  as  the 
remaining  portions  of  the  cortical  layer  and  the  spongiosa. 

In  conclusion,  it  may  be  stated  that  the  spongiosa  of  the  upper 
extremity  of  the  femur  is  derived  directly  from,  and  at  the  expense 
of  the  compact  layer;  that  it  is  constructed  upon  a  definite  plan  in 
a  series  of  arches  arranged  in  such  a  manner  as  to  resist  the  great- 
est amount  of  vertical  pressure  according  to  well-established  archi- 
tectural laws;  and  at  the  same  time,  that  by  expanding  the  bone  it 


ANATOMY   OF   THE   NECK   OF   THE   FEMUR.  17 

furnishes  a  more  extensive  surface  for  muscular  attachments,  and 
imparts  to  it  a  greater  degree  of  elasticity. 

The  exact  point  of  insertion  of  the  capsular  ligament  into  the 
femoral  neck  has  been  a  frequent  source  of  dispute  among  anato- 
mists and  surgeons  in  deciding  the  location  of  fractures  in  this 
locality.  Great  discrepancies  on  this  point  may  be  found  in  our 
anatomical  text-books. 

To  Dr.  Geo.  K.  Smith  much  credit  is  due  for  the  light  he  has 
thrown  on  this  subject.1  By  injecting  the  capsule  of  the  hip-joint 
with  air  or  plaster-of-paris  he  was  enabled  to  make  very  careful 
dissections,  and  by  measuring  accurately  the  distance  between  the 
corona  of  the  head  and  the  insertion  of  the  ligament,  and  from  this 
point  to  the  intertrochanteric  lines,  he  could  locate  the  exact  point 
of  insertion.  After  preparing  and  measuring  sixty-one  specimens 
in  this  manner  he  came  to  the  following  important  conclusions : 

"1.  That  scarcely  any  two  specimens  of  the  normal  capsule, 
taken  from  different  subjects,  are  alike  in  their  insertion  into  the 
neck  of  the  bone;  consequently  no  definite  description  of  its  inser- 
tion can  be  given. 

"  2.  That  the  normal  capsules  of  the  opposite  femurs  of  the 
same  subject  are  alike  in  their  insertion.  Having  measured  twenty- 
four  pairs  I  have  yet  to  see  a  single  variation  from  this  rule.  More- 
over, it  is  just  what  we  must  expect  to  find  in  obedience  to  that  law 
of  symmetrical  conformation  which  pervades  the  animal  economy." 

Morris"  locates  the  femoral  insertion  of  the  capsular  ligament 
as  follows:  "  At  the  femur  the  capsule  is  fixed  to  the  anterior  portion 
of  the  upper  border  of  the  great  trochanter,  and  to  the  tubercle  of 
the  femur  close  to  the  insertion  of  the  gluteus  minimus  and  the 
origin  of  the  vastus  externus,  with  slips  from  each  of  which  it  is 
blended.  Thence  it  runs  along  the  upper  and  outer  part  of  the  ante- 
rior inter-trochanteric  line,  but  soon  gets  below  it,  and  at  the  inner 
border  of  the  femur  is  on  the  level  of  the  lower  surface  of  the 
small  trochanter.  It  is  then  inclined  upward  and  backward  along 
an  oblique  line,  two-thirds  of  an  inch  in  front  of  the  small  trochan- 
ter, to   reach   the  back  of  the  neck;  here   it  is  attached  above  the 

1  The  Insertion  of  the  Capsular  Ligament  of  the  Hip-joint,  and  its  Rela- 
tion to  Intracapsular  Fracture.     New  York,  1862. 

2  The  Anatomy  of  theJointsof  Man.     Philadelphia,  1879,  p.  322. 


18  EXPERIMENTAL  SURGERY. 

posterior  intertrochanteric  line  at  a  distance  varying  from  half  an 
inch,  at  the  lower  and  upper  ends,  to  over  two-thirds  of  an  inch 
opposite  the  middle  of  that  line.  .  .  .  After  laying  open  the 
capsule  it  is  seen  that  some  of  the  deeper  fibres  of  this  ligament  are 
reflected  upward  along  the  neck,  so  as  to  be  attached  to  the  femur 
much  nearer  its  head.  These  reflected  fibres  occur  at  three  places, 
one  corresponding  in  position  to  the  middle  of  the  iliofemoral  liga- 
ment, another  to  the  pectineo-femoral,  and  the  third  on  the  upper  and 
back  part  of  the  neck.  A  thin  fold  of  synovial  membrane  stretches 
between  the  reflected  and  the  unreflected  fibres  of  the  capsule." 

These  strong  bands  of  reflected  fibres  have  been  called  reti- 
nacula  by  Weitbrecht.  Packard,  in  his  paper  previously  alluded  to, 
has  called  attention  to  the  existence  of  pockets,  usually  three  in 
number,  between  the  reflected  fibres. 

Kudinger, '  in  speaking  of  the  fibrous  capsule  of  the  hip-joint, 
says:  "Its  attachment  to  the  lateral  portions  of  the  neck  is  in  such 
a  manner,  that  anteriorly  it  reaches  the  anterior  inter-trochanteric 
line;  posteriorly,  on  the  other  hand,  it  reaches  only  as  far  as  the 
middle  of  the  neck." 

Practically,  we  can  safely  say,  that  the  anterior  portion  of  the 
capsular  ligament,  as  a  rule,  is  inserted  into  the  anterior  inter- 
trochanteric line,  reaching  its  lowest .  level  on  the  lower  surface  of 
the  lesser  trochanter,  while  the  posterior  portion  is  usually  inserted 
at  or  near  the  middle  of  the  femoral  neck.  A  close  inspection  of 
the  posterior  segment  of  the  capsular  ligament  will  usually  reveal 
the  existence  of  more  or  less  fibres  running  from  the  insertion  of 
the  ligament  proper  towards  the  inter-trochanteric  ridge.  For  our 
purpose  it  is  also  proper  to  mention  that  the  largest  nutrient  vessels 
to  the  neck  pass  beneath  the  reflected  portions  of  the  ligament. 

The  ligamentum  teres  will  receive  mention  only  as  far  as  it 
serves  as  a  earner  of  blood-vessels  to  the  head  of  the  femur.  In 
infants  it  contains  a  number  of  blood-vessels  which  enter  the  head 
of  the  femur  at  the  point  of  insertion  of  the  ligament  in  the  fovea. 
That  the  blood  supply  from  this  source  is  not  essential  for  the 
growth  and  development  of  the  upper  extremity  of  the  thigh-bone, 
is  apparent  from  the  fact  that  it  is  wanting  in  many  animals,  as  the 

1  Topographisch-chirurgische  Aiiatomie  des  Menschen.     Stuttgart,  1873, 
p.  142. 


ANATOMY   OF   THE  NECK   OF  THE   FEMUR.  19 

Bradypus,  Echidna,  Cholaepus,  elephant,  rhinoceros,  and  others. 
According  to  Savory,  two  hip-joints  were  examined  at  St.  Bartholo- 
mew's Hospital,  in  which  no  trace  of  this  ligament  could  be  found, 
but  the  head  of  the  femur  presented  a  depression,  not  covered  with 
cartilage,  at  the  usual  point  of  insertion  of  this  ligament.  There 
can  be  no  doubt  that  in  infants  the  vessels  of  this  ligament  penetrate 
the  bone  and  furnish  material  for  ossification  to  the  epiphysis  of 
the  femur.  After  the  growth  of  the  bone  has  been  completed,  the 
vessels  diminish  in  size  with  advancing  age,  and  disappear  entirely 
at  their  point  of  entrance  into  the  bone  in  a  certain  percentage  of 
cases.  Hyrtl  has  asserted  that  the  vessels  from  the  capsule  which 
pass  along  the  ligamentum  teres  to  the  surface  of  the  head  do  not 
communicate  with  the  vessels  of  the  medullary  substance,  but  return 
in  the  form  of  loops. 

In  one-third  of  the  specimens  examined  by  Welcker,  '  no  fora- 
mina nutritia  could  be  found  in  the  fovea  capitis;  hence,  he  con- 
cluded that  the  round  ligament  is  not  destined  to  act  as  a  carrier 
for  nutrient  vessels.  Sappey,  on  the  other  hand,  attributes  to  the 
ligamentum  teres  the  function  of  protecting  the  vessels  and  nerves 
that  nourish  the  head  of  the  femur. 

Langer"  has  made  careful  injections  of  the  vessels  of  the  hip- 
joint,  and  has  observed  that  not  all  of  the  vessels  of  the  ligamentum 
teres  return  in  loops  on  reaching  the  bone,  as  described  by  Hyrtl, 
but  that  some  of  them  penetrate  into  the  spongiosa  of  the  head  of 
the  femur.  I  have  examined  a  number  of  specimens  with  reference 
to  this  point,  and  have  been  able  to  detect  with  the  naked  eye 
nutrient  foramina  in  the  fovea  capitis  in  more  than  one-half  of  them. 
When  the  foramina  were  of  considerable  size,  I  have  been  able  to 
trace  them  for  some  distance  into  the  bone.  In  such  specimens 
there  can  be  no  doubt  as  to  the  presence  of  blood-vessels  from  the 
round  ligament  in  the  interior  of  the  spongy  tissue  of  the  head  of 
the  femur,  where  the  vessels  from  the  round  ligament  enter  into 
anastomosis  with  vessels  from  the  bone,  and  render  material  assist- 
ance in  maintaining  the  circulation  in  the  head  of  the  femur.  In 
some  specimens  the  foramina  may  be  so  small  as  to  elude  detection 
with  the  naked  eye,  but  may  nevertheless  admit  small  vessels  which 

1  Virchow  u.  Hirsch's  Jahresbericht,  vol.  i,  1875,  p.  9. 

2  Rttdinger,  op.  cit.,  p.  144. 


20  EXPERIMENTAL  SURGERY. 

* 
may  be  of  some  importance  in  furnishing  material  for  nutrition  in  the 
bone.  The  absence  or  destruction  of  the  vessels  of  the  ligamentum 
teres  may  not  interfere  with  the  growth  and  development  of  the 
bone  as  long  as  the  normal  supply  through  the  neck  of  the  femur  is 
not  impaired;  but  in  case  of  fracture  of  the  neck  they  are  of  great 
importance,  and  assume  a  compensating  function  in  harmony  with 
similar  processes  in  other  parts  of  the  body.  Rudimentary  small 
vessels  may  assume  vicarious  action  for  the  purpose  of  answering  an 
increased  demand,  and  thus  supply  a  sufficient  amount  of  blood, 
not  only  for  maintaining  the  vitality  of  the  upper  fragment,  but  also 
to  furnish  material  for  repair. 

IV.    Classification  of  Fractures  of  the  Neck  of  the  Femur. 

Since  the  teachings  of  Sir  Astley  Cooper  on  this  subject,  it  has 
been  customary  to  classify  fractures  of  the  cervix  femoris  according 
to  the  relative  position  the  capsular  ligament  bears  to  the  seat  of 
fracture,  into  the  intra-capsular  and  extracapsular  fractures,  to 
which  has  been  added  a  third  variety,  fractures  partly  within  and 
partly  without  the  capsular  ligament.  The  mixed  variety  has  given 
rise  to  a  good  deal  of  confusion,  as  some  have  included  it  among 
intracapsular  fractures,  while  others  class  it  with  extracapsular 
fractures.  Since  it  has  been  ascertained  that  many  of  the  fractures 
of  the  neck  of  the  femur  are  impacted,  those  who  have  placed  great 
prognostic  and  therapeutic  importance  upon  this  condition,  have 
made  impaction  the  basis  for  a  new  classification,  and  speak  of 
impacted  and  non- impacted  fractures  of  the  neck  of  the  femur. 
Among  those  who  favored  this  classification  may  be  enumerated 
Cloquet,  Josselin,  Duplay,  Bigelow,  Bryant,  Hueter,  and  Lossen. 

The  distinction  into  impacted  and  non-impacted  fractures  is 
important  in  a  clinical,  diagnostic,  prognostic,  and  therapeutic  sense, 
while  the  division  into  intra-capsular  and  extra-capsular  fractures 
has  a  very  important  pathological  significance.  Fractures  of  the 
neck  of  the  femur  with  impaction  will  unite  by  bony  union  irrespec- 
tive of  the  situation  of  the  capsular  ligament,  provided  the  impaction 
is  maintained  for  a  sufficient  length  of  time.  Fractures,  impacted 
or  non-impacted,  outside  of  the  capsular  ligament  will  unite  in  the 
same  manner  as  fractures  in  any  other  locality,  if  the  fractured  ends 
are  kept  in  apposition  and  immobilized  for  the  necessary  length  of 


CLASSIFICATION   OF  FRACTURES   OF  NECK  OF  FEMUR.        21 

time.  Fractures  at  the  narrow  part  of  the  neck,  and  entirely  within 
the  capsule,  can  only  unite  by  bone,  if  the  penetration  is  such  as  to 
secure  apposition  for  a  number  of  weeks,  or  if  the  same  degree 
of  apposition  and  immobilization  is  effected  by  surgical  procedures. 
The  frequency  with  which  impaction  occurs  in  the  femoral  neck,  and 
the  important  part  it  performs  in  the  reparative  process,  entitle  it  to 
a  permanent  place  as  a  basis  for  classification. 

When  we  are  able  to  diagnosticate  the  existence  of  an  impacted 
fracture  of  the  neck  of  the  femur,  all  efforts  to  locate  the  exact  seat 
of  fracture  are  perfectly  useless,  as  it  could  have  no  influence  in 
selecting  therapeutic  measures,  and  might  eventuate  disastrously  by 
abolishing  the  most  favorable  conditions  for  a  fortunate  issue.  If 
we  adopt  the  proposition,  that  fractures  of  the  femoral  neck  with 
penetration  can,  and  often  do  unite  by  bone,  irrespective  of  their 
relative  position  to  the  capsular  ligament,  then  the  distinction 
between  fractures  within  and  without  the  capsular  ligament  can 
only  find  a  practical  application  in  the  examination  of  specimens  to 
prove  or  disprove  the  correctness  of  the  proposition.  This  holds 
the  more  true  as,  in  vivo,  all  known  diagnostic  means  have  proved 
unreliable  in  locating  the  exact  point  of  fracture.  The  sooner  the 
profession  can  be  convinced  that  intra-capsular  fractures  also  unite 
by  bony  union  under  certain  favorable  conditions,  the  better  will  it 
be  to  abandon  the  old  classification,  which  has  proved  to  be  incorrect 
anatomically,  and  unwarranted  by  pathological  facts.  Practically, 
then,  it  is  always  important  so  ascertain  the  presence  of  impaction, 
and  not  to  interfere  with  it  when  found;  theoretically,  and  for  the 
purpose  of  adopting  therapeutic  measures,  it  is  desirable  in  non- 
impacted  fractures  to  locate  as  nearly  as  possible  the  seat  of  fracture 
without  inflicting  unnecessary  violence. 

In  the  light  of  recent  anatomical  investigation  and  pathological 
research,  and  for  the  purpose  of  avoiding  unnecessary  confusion,  it 
would  be  advisable  to  limit  the  term  intra-capsular  to  all  fractures 
that  do  not  extend  beyond  the  insertion  of  the  capsular  ligament, 
and  to  include  among  the  extra-capsular  fractures,  the  so-called 
mixed  and  purely  extra- capsular  fractures.  Remembering  the 
attachment  of  the  anterior  portion  of  the  capsular  ligament  we 
would  naturally  infer  that  purely  extra-capsular  fractures,  without 
further  injury  to  the  shaft  of  the  femur,  if  possible  at  all,  must  he 
exceedingly  rare.     The  greatest  number  of  extra-capsular  fractures, 


22  EXPERIMENTAL  SURGERY. 

as  described  by  our  text-books,  have  belonged  to  the  mixed  variety; 
intra-capsular  in  front,  extra-capsular  behind.  In  speaking  of 
extra-capsular  fractures,  Dr.  R.  W.  Smith  says:  "All  extra- capsular 
fractures  are,  in  the  first  instance,  also  impacted  fractures,  and  all 
impacted  fractures  are  necessarily  accompanied  by  a  fracture  travers- 
ing some  part  of  the  trochanteric  region.  I  have  omitted  no  oppor- 
tunity of  investigating  this  point,  and  have  now  examined  here  and 
elsewhere  upwards  of  one  hundred  specimens  of  the  extra-capsular 
fracture,  and  have  found  in  all,  without  a  single  exception,  a  second 
fracture  traversing  some  portion  of  the  intertrochanteric  space." 

In  commenting  on  the  paper  of  Dr.  G.  K.  Smith,1  Dr.  Post 
suggested  to  substitute  for  intra-capsular  and  extracapsular,  the 
terms  intra-cervical  and  extra  cervical;  the  latter  designation  to 
indicate  an  impacted  fracture  at  the  base  of  the  neck  with  more  or 
less  injury  of  the  femoral  shaft.  As  under  this  classification  intra- 
cervical  fractures  would  include  intracapsular  and  mixed  fractures, 
and  the  term  extra-cervical  would  imply  the  existence  of  a  fracture 
rather  beyond  than  in  the  cervix  itself,  these  terms  are  not  of  suffi- 
ciently accurate  anatomico-pathological  precision  to  recommend 
themselves  for  general  adoption,  although  they  are  full  of  practical 
significance.  Inasmuch  as  the  principal  object  in  writing  this  article 
has  been  to  prove  that  bony  union  after  intracapsular  fractures  can 
take  place,  the  terms  intra-capsular  and  extracapsular  have  been 
retained,  but  will  be  applied  in  the  sense  previously  suggested. 

T.    Relative  Number  of  Intra-  and  Extra-Capsular 
Fractures. 

The  inability  to  accurately  locate  the  fracture  during  life,  and 
the  existing  confusion  and  uncertainty  as  to  the  meaning  and  appli- 
cation of  the  terms  intra-  and  extracapsular  in  the  description  of 
specimens  have  rendered  the  statistics  on  this  point  unsatisfactory 
and  unreliable.  Although  the  cervix  femoris  may  be  broken  at  any 
point  between  the  head  of  the  femur  and  the  inter-trochanteric 
ridges,  there  are  certain  points  where  it  is  more  liable  to  give  way. 
The  exact  location  of  the  fracture  is  determined  to  a  great  extent  by 
the  seat  and  degree  of  senile  osteo-porosis,  and  the  direction  of  the 
fracturing  force.     Senile  osteo-porosis,  as  we  have  seen,  begins  in 

1  Op.  cit.,  p.  35. 


STATISTICS   OF  FRACTURES.  23 

the  spongiosa,  and  reaches  its  maximum  degree  soonest  at  the  con- 
tracted portion  of  the  neck;  hence  fracture  nearest  the  head  is  most 
likely  to  take  place  in  decrepit  old  people.  Fractures  at  this  point 
arc  exceedingly  rare  in  persons  less  than  fifty  years  of  age,  only  a 
very  few  well-authenticated  cases  being  on  record. 

Kodet,  in  a  series  of  experiments  on  the  femur  and  on  plaster - 
of-paris  casts  of  the  upper  extremity  of  this  bone,  has  demonstrated 
the  important  fact,  that  the  situation  and  direction  of  a  fracture 
of  the  neck  of  the  femur  may  be  predicted  to  almost  a  certainty,  by 
a  knowledge  of  the  direction  in  which  the  force  was  applied.  Thus,  a 
force  acting  vertically  will  produce  an  oblique  intra-capsular  fracture; 
a  force  acting  from  before  backward,  a  transverse  intra-capsular 
fracture;  one  from  behind  forward,  a  fracture  partly  within  and 
partly  without  the  capsule;  and  a  force  applied  transversely,  a  frac- 
ture entirely  without  the  capsxile.  Clinical  evidence  has  repeatedly 
verified  the  correctness  of  these  observations.  The  traction  fractures 
described  by  Linhart,  Riedinger,  and  Hueter,  from  the  powerful 
traction  of  the  ilio- femoral  ligament,  when  the  thigh  is  over- 
extended and  adducted,  invariably  fall  outside  of  the  limits  of  the 
capsule. 

Bonnet  believed  that  the  line  of  fracture  was  almost  always 
without  the  capsule,  and  Nedaton  contended  that  in  the  great 
majority  of  cases  he  made  the  same  observation;  while  many  authors, 
equally  competent,  among  them  Sir  Astley  Cooper,  Ashhurst,  and 
Druitt,  claim  that  intracapsular  fracture  occurs  more  frequently  in 
persons  above  fifty  years  of  age.  Of  twelve  specimens  examined 
in  the  museum  of  St.  Bartholomew's  Hospital  by  Stanley,  six  were 
supposed  to  be  intra-capsular,  and  six  extra-capsular. 

Malgaigne1  examined  one  hundred  and  three  specimens  from 
different  sources  to  determine  the  relative  frequency  of  these  frac- 
tures, and  found  that  sixty-one  belonged  to  the  intra-capsular  to 
forty-two  of  the  extracapsular  variety. 

ML  Merrier,  at  Bicetre,  found  in  eight  autopsies  three  intra- 
capsular and  four  extra -capsular  fractures,  and  one  below  the  tro- 
chanters: while  Malgaigne  himself,  in  the  same  hospital,  found  in 
eight  other  autopsies  one  fracture  below  the  trochanters,  five  within 
the  capsule  and  only  two  outside  of  it.     Stimson2  made  a  post-mor- 

1  Treatise  on  Fractures.     Translated  by  J.  H.  Packard,  M.D.,  1859,  p.  533. 

2  A  Treatise  on  Fractures,  1883,  p.  491. 


24  EXPERIMENTAL   SURGERY. 

tern  examination  in  six  cases,  and  ascertained  that  in  two  of  them 
the  fracture  was  purely  intracapsular,  and  that  in  four,  the  fracture 
was  at  the  junction  of  the  neck  and  shaft. 

Heppner1  gives  a  description  of  five  cases  of  impacted  fracture 
of  the  neck  of  the  femur,  of  which  number  three  were  extracapsular 
and  two  intra-capsular.  Of  twenty-three  specimens  of  fracture  of 
the  neck  of  the  femur,  in  the  Museums  of  the  College  of  Physicians, 
Philadelphia,  and  the  University  of  Pennsylvania,  examined  by 
Agnew,3  ten  were  within  and  thirteen  without  the  capsular  ligament. 
Mussey's  collection  contains  twelve  examples  of  fracture  of  the 
femur  without,  and  ten  within  the  capsule. 

The  above  statistics  embrace  one  hundred  and  eighty-five  post- 
mortem specimens,  of  which  number  ninety-nine  were  fractures 
within,  and  eighty -six  without  the  capsular  ligament;  figures  which 
would  tend  to  prove  that  intra- capsular  fractures  are  more  frequent 
than  fractures  without  the  capsule.  It  must,  however,  be  remem- 
bered that  many  of  these  specimens  were  collected  for  a  special 
purpose,  and  on  that  account  the  numbers  do  not  represent  the  true 
proportion  as  it  actually  exists.  If  the  statistics  obtained  by  the 
examination  of  post-mortem  specimens  are  not  reliable  in  ascertain- 
ing the  relative  frequency  with  which  these  fractures  occur,  the 
information  derived  from  clinical  observation  must  prove  still  less 
satisfactory  in  deciding  this  question,  as  the  symptoms  during  life 
are  not  sufficiently  well  marked  to  enable  the  surgeon  to  locate  with 
certainty  the  exact  seat  of  fracture. 

Billroth3  refers  to  twenty-seven  cases  of  fracture  of  the  neck  of 
the  femur,  of  which  number  thirteen  were  diagnosticated  as  intra- 
capsular, and  fourteen  extra -capsular.  In  Dr.  Hyde*s  table  of  three 
hundred  and  twenty-one  cases  of  fracture  of  the  femur,  we  find  that 
the  neck  was  involved  thirty-one  times;  these  were  supposed  to  be 
located  fourteen  times  within  and  seventeen  times  without  the 
capsule. 

Hamilton4  has  recorded  eighty-four  cases  of  fracture  of  the 
femoral  neck  from  his  own  personal  observation ;  of  these,  forty  were 

1  Beobachtungen  u.  Untersuchungen  tiber  die  Schenkelhalsbrueche. 
Oestr.  Med.  Jahrb.  Heft.  3  u.  4,  1870. 

2  Principles  and  Practice  of  Surgery,  vol.  i.,  1878,  p.  931. 

3  Chirurgische  Klinik.  Wien,  1879. 

4  A  Practical  Treatise  on  Fractures  and  Dislocations,  1880,  p.  393. 


INCOMPLETE   FRACTURES.  25 

believed  to  be  without  the  capsule,  and  thirty  were  believed  to  be 
within,  the  remainder  were  undetermined.  These  statistics  furnish 
one  hundred  and  twenty-eight  cases  with  fifty-seven  intracapsular, 
and  seventy-one  extracapsular  fractures,  a  majority  in  favor  of  the 
extra  capsular  variety. 

Combining  the  figures  from  the  museum  specimens  and  those 
taken  from  bedside  observation  we  obtain  three  hundred  and  thirteen 
cases  of  fracture  of  the  neck  of  the  femur,  of  which  number  one 
hundred  and  fifty-six  were  supposed  to  be  located  within,  and  one 
hundred  and  fifty-seven  without  the  capsular  ligament. 

VI.    Incomplete  Fractures  of  the  Neck  of  the  Femur. 

The  structure  of  the  neck  of  the  femur  in  the  aged  furnishes 
conditions  unusually  favorable  for  the  occurrence  of  partial  or 
incomplete  fracture.  Although  this  form  of  fracture  has  received 
but  little  attention  on  the  part  of  surgical  writers,  receiving  at  the 
best  only  brief  mention,  it  would  appear  from  the  cases  reported 
during  the  last  few^vears,  that  the  accident  is  not  as  rare  as  has  been 
supposed.  Colles '  was  the  first  to  call  attention  to  this  variety  of 
fracture  as  it  occurs  in  the  neck  of  the  femur,  and  described  three 
cases.  Dr.  J.  B.  S.  Jackson,  of  Boston,  described  a  case  of  incom- 
plete fracture  (fissure),  the  line  of  fracture  extending  from  the 
junction  of  the  upper  border  of  the  neck  with  the  head  downward  to 
within  a  quarter  of  an  inch  of  the  inferior  and  internal  wall  of  the 
bone. 

Gurlt"  mentions  three  cases.  In  Tournel's  case  the  infraction 
took  place  at  the  upper  portion  of  the  base  of  the  neck,  the  line  of 
fracture  running  from  the  digital  fossa  downward.  In  the  case 
reported  by  P.  Wilkinson  King,  the  line  of  fracture  was  near  the 
head  of  the  femur,  a  bridge  of  compact  tissue  on  the  anterior  and 
upper  portion  of  the  neck,  one-third  the  circumference  of  the  com- 
pacta  remaining  intact.  The  third  described  be  found  in  the  Patho- 
logical Museum  in  Giessen.  The  transverse  infraction  affected  the 
entire  posterior  half  of  the  femoral  neck  about  its  middle,  while  the 
anterior  wall  was  not  affected.  The  margins  of  the  fractured 
surfaces  were  in  immediate  contact. 

1  Dublin  llo>|>it,-il  Reports,  \<>1.  ii. 
'  Knochenbrueche,  vol.  i.  p,  31. 


26  EXPERIMENTAL   SURGERY. 

Koenig1  described  two  specimens.  In  the  first  specimen  the 
line  of  fracture  occurred  on  the  upper  and  posterior  surface  of  the 
neck,  near  the  head,  with  impaction  of  the  cervical  portion  into  the 
head,  while  the  compact  tissue  on  the  anterior  and  inferior  surface 
remained  entire.  In  the  second  specimen,  the  line  of  infraction  took 
place  at  the  lower  surface  of  the  neck,  at  the  most  constricted  por- 
tion, with  penetration  of  the  apex  of  Adams'  arch  into  the  interior 
of  the  head,  while  the  upper  portion  of  the  neck  had  yielded  with- 
out being  broken.      (Figs.  5  and  6.) 

These  two  varieties  Koenig  considers  as  representing  typical 
forms  of  this  fracture,  the  mechanism  of  their  production  being  the 
same  as  in  complete  fractures  of  the  neck.  In  the  first  variety,  from 
the  direction  of  the  impaction  the  limb  is  rotated  outward,  while  in 
the  second  form  the  foot  remains  in  its  natural  position,  but  the 
limb  is  shortened  in  proportion  to  the  extent  of  the  impaction. 
Koenig  is  of  the  opinion  that  many  of  the  cases  of  complete 
recovery  after  supposed  intracapsular  fractures,  were  cases  of 
incomplete  fracture  with  impaction.  At  the  same  meeting,  Billroth 
reported  two  cases  where  he  made  the  diagnosis  of  incomplete  frac- 
ture during  life;  in  both  instances  recovery  was  imperfect. 

Incomplete  fractures  of  the  neck  of  the  femur,  as  well  as  of 
other  bones,  consist  of  a  loss  of  continuity  of  a  certain  number  of 
cancelli,  forming  the  substance  of  bone.  It  may  exist  in  every 
degree,  from  a  fracture  almost  complete  to  one  in  which  the  number 
of  severed  cancelli  is  so  small  as  to  elude  detection  by  the  naked  eye. 
The  location  and  direction  of  the  line  of  infraction,  as  in  complete 
fractures,  must  necessarily  vary  according  to  the  direction  in  which 
the  force  is  applied  which  produces  the  fracture.  Stimson2  says: 
"  The  line  of  fracture  is  transverse  and  upon  the  concave  side,  and 
is  produced  by  crushing,  not  by  overbending."  Incomplete  fractures 
are  repaired  by  the  formation  of  intermediate  callus  between  the 
fractured  surfaces,  which  restores  the  continuity  of  the  bone.  The 
unbroken  portions  of  the  bone  and  periosteum  serve  as  a  perfect 
splint,  which  secures  complete  rest  and  apposition  until  the  injury 
is  repaired.  The  deformity  attending  this  accident  is  necessarily 
always  very  slight,  and  as  the  symptoms  at  the  same  time  are  not 

1  Verhandlungen  der  Deutschen  Gesellschaft  f.  Chirurgie,  1877,  p.  131. 

2  A  Treatise  on  Fractures,  1883,  p.  41. 


IMPACTED   FRACTURES. 


27 


pronounced,  the  diagnosis  must  always  remain  uncertain.  The 
cases  are  most  likely  to  be  mistaken  for  contusion  of  the  hip;  hence, 
we  should  always  examine  the  severer  injuries  about  the  hip  with 
unusual  care,  and  if  any  doubt  exists,  give  the  patient  the  benefit  of 
such  doubt,  and  treat  the  case  as  one  of  incomplete  or  complete 
fracture  with  impaction. 


Fig. 


Fig.  6. 


Partial  Fracture  of  Neck  of  Femur.     (Koenig. 


VII.    Impacted  Fractures  of  the  Neck  of  the  Femur. 

Impaction,  penetration,  implantation,  and  incuneation,  are 
synonymous  terms,  which  are  used  to  describe  a  fracture  when  one 
fractured  end  is  driven  into  the  other,  an  occurrence  which  secures 
perfect  coaptation  and  fixation.  In  some  instances  impaction  is 
mutual.  Impaction  may  be  complete  or  incomplete,  according  to 
the  tissue  structure  at  the  seat  of  the  fracture,  or  the  direction  and 
intensity  of  the  fracturing  force.  Impacted  fractures  are  most 
frequently  met  with  in  the  spongy  portions  of  the  long  bones,  and 
in  persons  suffering  from  osteo-porosis  from  any  cause.  These 
fractures  have  only  quite  recently  become  the  objed  of  special 
investigation,  and  arc  at  the  present  time  receiving  the  attention 
their  importance  merits. 

Robert  was  the   lirst  to  give  a  good  description  of  impacted 


28  EXPERIMENTAL   SURGERY. 

fracture  of  the  neck  of  the  femur,  and  explain  its  mechanism.  He 
specified  the  following  conditions  which  must  be  present  for  pene- 
tration to  take  place:  In  the  first  place,  the  penetrating  bone  must 
have  a  conical  shape,  and  must  be  placed  opposite  a  spongy  section 
of  bone,  and  must  have  been  broken  off  close  to  the  insertion  of 
the  same.  The  impacting  force  must  be  applied  in  the  direction 
of  the  long  axis  of  the  incuneated  bone.  All  these  conditions  are 
presented  in  fractures  through  the  neck  of  the  femur.  Adams 
regarded  the  inner  and  lower  compact  tissue  of  the  neck  of  the 
femur  as  the  principal  element  of  impaction;  the  direction  of  the 
fracture  through  the  neck  being  oblique  from  above  downward, 
fractures  the  arch  in  such  a  way  that  the  apex,  sharp  and  pointed,  is 
placed  opposite  the  loosely  cancellated  tissue  of  the  shaft,  into  which 
it  is  driven  by  the  same  force  which  fractured  the  bone. 

Streubel  looked  upon  senile  osteo-porosis  as  the  main  cause  of 
impaction.  It  is  necessary,  however,  that  the  compacta  of  the 
fractured  neck  retain  sufficient  firmness  to  penetrate  the  bone  with- 
out being  comminuted.  Some  authors  assert  that  impaction  follows 
fracture  in  such  a  way  that  the  neck  of  the  femur  gives  way  to 
indirect  violence  from  a  fall  upon  the  foot  or  knee,  the  impaction 
following  by  the  patient  falling  upon  the  trochanter.  Heppner 
assumes  that  the  relation  existing  between  the  neck  of  the  femur  and 
the  trochanteric  portion  of  the  femur  is  the  cause  of  impaction,  and 
takes  into  special  consideration  the .  spongiosa  in  which  he  disting- 
uishes two  distinct  layers,  of  which  one  possesses  a  greater  degree 
of  density  than  the  other.  He  believes  fracture  at  the  base  of  the 
neck  with  impaction  is  always  the  result  of  force  applied  to  the 
trochanter  major,  which  expends  itself  at  the  origin  of  the  femoral 
brace,  and  fractures  the  entire  base  of  the  cervix.  Aside  from  the 
diminution  in  the  obliquity  of  the  cervix,  and  the  presence  of  senile 
osteo-porosis,  he  finds  another  cause  for  this  fracture  in  the  general 
atrophy  of  the  aged,  rendering  the  trochanter  major  more  prominent 
and  thus  more  directly  exposed  to  external  violence.  The  last 
assertion,  however,  is  not  in  accord  with  experience,  as  corpulent 
aged  females  furnish  the  largest  number  of  fractures  of  the  femoral 
neck. 

Streubel  made  some  experiments  on  cadavers  to  determine  the 
seat  of  fracture  on  the  application  of  direct  and  indirect  violence. 
To  test  the  effect  of  violence  applied  in  the  axis  of  the  femur,  he 


IMPACTED    FRACTURES.  29 

amputated  the  thigh  and  applied  the  force  directly  to  the  sawed 
surface  of  the  femur,  and  succeeded  only  in  one  instance  in 
producing  an  intracapsular  fracture.  By  applying  the  force  to 
the  trochanter  major  he  produced  one  extra-capsular  impacted  frac- 
ture, while  in  all  other  cases  the  trochanter  major  was  fractured. 
Heppner  repeated  these  experiments  with  the  same  results.  He  then 
reversed  the  direction  of  the  force.  Taking  a  femur,  stripped  of  its 
soft  parts,  and  resting  the  outer  surface  of  the  trochanter  major 
upon  a  table,  he  struck  the  head  of  the  femur  with  an  axe,  and 
produced  in  every  instance  a  fracture  of  the  neck  resembling  an 
impacted  fracture.  He  repeated  the  experiment  thirty  times,  and  in 
five  of  the  cases  the  impaction  was  typical.  From  these  experiments 
he  has  drawn  the  deduction,  that  the  fracture  is  produced  by  contre- 
coup,  whether  the  force  is  applied  to  the  trochanter  major  or  through 
the  axis  of  the  femur. 

In  regard  to  impaction  of  intra-capsular  fractures  he  could  find 
nothing  in  the  literature  on  the  subject  of  fractures  of  the  femoral 
neck.  Vollemier  speaks  of  them  at  length,  but  only  for  the  purpose 
of  denying  their  occurrence.  But,  inasmuch  as  he  states  that  he  has 
seen  several  specimens  where  the  end  of  Adams'  arch  was  found  to 
terminate  in  the  interior  of  the  spongy  portion  of  the  head  of  the 
femur,  he  contradicts  himself,  as  the  description  corresponds  with 
impaction  of  the  lower  wall  of  the  femoral  arch  into  the  head.  The 
question  at  issue  is  not  the  degree  of  impaction,  but  whether  it  can 
secure  mutual  fixation  of  the  fragments.  In  most  cases  only  the 
lower  edge  of  the  outer  fragment  is  impacted,  but  the  contrary  may 
take  place,  as  is  evident  from  the  description  given  by  Koenig  under 
the  head  of  partial  fractures. 

For  one  of  the  best  contributions  to  our  knowledge  of  impacted 
fractures  of  the  neck  of  the  femur  we  are  indebted  to  Riedinger.1 
He  has  studied  this  subject  by  experiments  and  examination  of 
museum  specimens.  In  speaking  of  intra-capsular  fractures,  he  says 
that,  as  a  rule,  the  lower  and  more  particularly  the  posterior  wall  of 
the  lower  fragment  is  driven  into  the  spongiosa  of  the  head.  As  a 
necessary  consequence  of  this  form  of  impaction,  the  head  of  the 
femur  is  depressed  and  inclines  backward,  sometimes  to  such  an 
extent   as  to  come  in  contact  with  the  posterior  intertrochanteric 

1  Studies  abet  Grund  und  Einkeilung  der  Schenkelhalsbrueohe,  Wtirzburg, 

1-71. 


30  EXPERIMENTAL   SURGERY. 

line.  The  cortical  portion  of  the  lower  fragment  can  often  be  traced 
into  the  interior  of  the  head  to  a  distance  of  two  centimetres.  At 
the  anterior  line  of  fracture  the  denticulated  margins  retain  such  a 
firm  grasp  as  to  add  materially  to  the  firmness  of  the  impaction.  At 
the  base  of  the  neck  of  the  femur  the  conditions  for  impaction  are 
most  favorable.  If  sufficient  force  is  applied  over  the  trochanter 
major,  the  neck  fractures  in  such  a  way  that  the  femoral  brace  is 
detached  near  its  origin,  and  constitutes  a  sharp  projection,  which, 
when  slightly  dislocated,  is  placed  vis-a-vis  to  the  spongy  tissue  of 
the  outer  fragment,  and  is  implanted  into  the  same  by  the  fracturing 
force.  The  upper  portion  of  the  inner  fragment,  although  not  pos- 
sessed of  an  analagous  dense  structure  as  the  femoral  brace,  follows 
in  the  penetrating  process  the  more  readily,  as  the  whole  inner  frag- 
ment is  wedge-shaped.  The  spongiosa  between  the  cortical  layers 
forms  a  somewhat  sharp  projection.  Impaction  of  the  base  of  the 
neck  is  carried  to  its  fullest  extent  in  case  the  fracturing  force  is 
sufficient  to  fracture  also  the  trochanteric  portion  of  the  femur.  In 
such  instances  the  apex  of  the  inner  fragment  sometimes  splits  the 
shaft  of  the  femur  into  a  number  of  fragments,  and  presents  itself 
on  the  outer  surface  of  the  bone  beneath  the  soft  parts. 

Mr.  Bryant1  has  published  a  table  of  fourteen  cases  of  impacted 
fracture  of  the  neck  of  the  femur,  and  from  an  analytical  study  of 
these  cases  he  draws  the  following  conclusions : 

"  1.  That  in  all  the  cases  the  injury  to  the  hip-joint  was  com- 
municated through  the  greater  trochanter. 

"2.  That,  as  a  result  of  the  injury,  there  was  more  or  less  loss 
of  power  in  the  limb ;  in  some  cases  it  was  complete,  in  as  many  the 
patient  could  rotate  the  limb  slightly  on  the  couch ;  and  in  two  cases 
partial  flexion  of  the  thigh  could  be  performed. 

"3.  That  in  all  the  cases  immediate  shortening  of  the  injured 
limb  was  the  direct  result  of  the  accident;  and  that  this  shortening 
was  about  an  inch  or  less,  and  it  was  irremediable  by  extension. 

"  4.  That  the  foot  of  the  injured  extremity  was  either  straight 
or  slightly  everted,  although  in  several  cases  this  eversion  was  less 
marked  on  the  injured  than  on  the  sound  side. 

"  5.     That  the  great  trochanter  was  placed  near  the  median  line 

1  Medical  Times  and  Gazette,  April  17  and  May  1,  1869. 


IMPACTED   FRACTURES.  31 

of  the  body,  and  also  nearer  the  anterior  superior  spinous  process  of 
the  crest  of  the  ilium  than  on  the  sound  side. 

"6.  That  the  head  of  the  femur  could  be  made  to  rotate 
smoothly  in  the  acetabulum,  and  the  great  trochanter  moved  with  it. 

"7.     That  crepitus  was  either  absent  or  indistinct  in  all  cases. 

"8.  That  all  the  cases,  with  one  exception,  occurred  in  patients 
past  middle  age." 

Bardeleben1  maintains  that,  in  intracapsular  fractures,  longitu- 
dinal displacement  is  opposed  by  the  untorn  portions  of  the  capsular 
ligament.  In  this  fracture  the  ends  of  the  fragments  are  often  inter- 
locked in  such  a  manner  as  to  prevent  dislocation,  and  may  even 
enable  the  patient  to  walk  on  the  limb  for  a  few  hours,  or  for  several 
days.  The  more  important  elements  in  retaining  the  fragments  are, 
however,  the  presence  of  impaction,  and  the  untorn  portions  of  the 
reflected  capsule,  the  retinacula  of  Weitbrecht. 

S.  D.  Gross  ~  believes  that  impaction  is  rare,  and,  when  present, 
is  almost  exclusively  extra-capsular.  The  distance  of  penetration 
varies  from  a  few  lines  to  one-half  or  three-quarters  of  an  inch. 

Hueter3  places  great  importance  in  recognizing  the  presence  of 
impaction.  He  regards  the  schenkelsporn  as  the  most  important 
agent  in  the  process  of  impaction.  Anatomically  he  distinguishes 
two  varieties:  either  the  upper  end  of  the  lower  fragment  is  dis- 
placed inward,  so  that  the  termination  of  the  schenkelsporn  pene- 
trates the  soft  tissues  below  the  upper  fragment,  or  the  lower  frag- 
ment is  displaced  outward  in  such  a  manner  that  the  schenkelsporn 
is  driven  into  the  spongiosa  of  the  neck.  Impacted  fractures  are 
not  so  frequent  as  non-impacted  fractures,  but  they  are  sufficiently 
common  to  render  them  of  the  greatest  importance  in  the  diagnosis, 
]  >n  'gnosis,  and  treatment  of  fractures  of  the  neck  of  the  femur. 

H.  H.  Smith4  believes  that  in  the  majority  of  cases  the  neck 
of  the  femur  is  fractured  by  indirect  violence,  impaction  following 
subsequently  by  a  fall  upon  the  trochanter  major.  R.  W.  Smith 
Bays:  ''That  all  extracapsular  fractures  are,  in  the  first  instance, 
also  impacted  fractures.'' 

1  Lehrbuch  der  Chirurgie.    Band  II,  1871,  S.  47.5. 

tem  of  Surgery,  vol.   i,  1864,  ]<.   966. 
'JGrundri>s  der  Chirurgie.    B.  II,  1882,  S.  883. 
*  The  Principles  and  Practice  of  Surgery,  1863. 


32 


EXPERIMENTAL   SURGERY. 


Robert1  was  of  the  opinion  that  fractures  of  the  neck  of  the 
femur  were  nearly  always  impacted,  and  as  such  should  be  disturbed 
as  little  as  possible  to  obtain  the  best  results,  as  the  impaction  fur- 
nished the  best  possible  conditions  for  bony  union  to  take  place. 
MacNamara 2  affirms  that  fractures  of  the  neck  of  the  femur  are 
usually  impacted,  the  fragments  being  jammed  into  one  another; 
the  smashed  cancellated  tissue  must  be  removed,  rendering  the  pro- 
cess of  repair  tedious. 

Bigelow/  who  has  devoted  a  great  deal  of  time  and  attention  to 
the  subject  of  injuries  about  the  hip-joint,  is  convinced  from  the 


Fig.  7.     Posterior  Impaction  of  Femoral  Neck.     (Bigelow.) 

views  he  entertains  as  to  the  architecture  of  the  femoral  neck,  that 
fracture  takes  place  most  frequently  at  the  base  of  the  neck,  and  is 
usually  accompanied  by  impaction  of  its  posterior  wall.  (Figs. 
7  and  8.)  These  cases  present  outward  rotation  of  the  limb,  and 
slight  shortening,  and  may  be  followed  by  complete  repair  without 
lameness. 

1  Memoire  sur  les  Fract.  du  col  de  Femer,  1845. 

2  Diseases  of  Bones  and  Joints,  1881. 

3  The  True  Neck  of  the  Femur,  Boston  Med.  and  Surg.  Jour.,  Jan.  7,  1875. 


IMP  A  CTED   FRA  CTURES. 


33 


Impaction  at  the  constricted  portion  of  the  neck  is  not  frequent. 
Impaction  of  the  entire  base  of  the  neck  with  inward  rotation  of 
the  limb  is  very  rare,  and  is  hardly  possible  without  fracture  of  the 
trochanters. 

The  same  author,  at  a  meeting  of  the  Boston  Society  for 
Medical  Improvement,  held  November  23,  1874,  exhibited  a  speci- 
men of   a  fracture  within  the   capsular   ligament  with   imperfect 


Fio.  8. 


Posterior  Impaction  of  Femoral  Neck. 
Section. 


(Bigelow.)     Transverse 


impaction,  which,  during  life,  had  simulated  impaction  at  the  base 
of  the  neck,  and  induced  him  to  express  a  favorable  prognosis. 
"  The  autopsy  showed  that  the  fracture  was  not  through  the  base  of 
the  neck,  but  through  the  neck  itself,  close  to  the  head,  and  that  the 
fragments  were  '  rabbeted '  together.  There  was  motion  enough  to 
have  worn  away  the  thin  walls  of  the  neck,  and  to  show  that  any 
bony  union,  had  the  patient  lived,  was  not  to  be  hoped  for.     In  this 


34  EXPERIMENTAL   SURGERY. 

respect  it  differed  from  Dr.  Gay's  case  of  impacted  fracture  into  the 
head,  where  the  patient,  on  the  day  of  his  death  from  pneumonia,  a 
week  or  two  after  the  accident,  lifted  up  his  leg  and  said  that  as  far 
as  that  went,  he  was  getting  well.  Had  that  man  lived,  he  would 
undoubtedly  have  had  bony  union  and  a  serviceable  leg.  The 
rabbeting  of  the  fragments  was  shown  here  very  well  in  the  present 
specimen.  It  was  due  to  a  conical  mass  of  comparatively  dense 
bony  tissue  projecting  from  the  head  fragment,  which  was  driven 
into  the  loose  cancellated  structure  of  the  portion  of  the  neck  in  the 
shaft  fragment.  This  dovetailing,  although  sufficient  while  the 
fragments  were  surrounded  by  the  capsule  and  soft  parts  to  prevent 
crepitus,  and  to  cause  the  neck  and  head  to  rotate  in  the  socket  as  a 
whole,  did  not  prevent  such  attrition  of  the  fragments  as  would 
hinder  bony  union." 

Koenig1  locates  fractures  of  the  neck  of  the  femur  either  near 
the  head  or  the  trochanteric  portion,  localities  which  correspond  to 
intra-  and  extra-capsular  fractures.  From  anatomical  reasons,  after 
a  fall  upon  the  trochanter  major,  the  anterior  wall  of  the  neck  (the 
convex  side)  fractures  first,  and  the  fractured  end  of  the  neck  is 
directed  forward.  In  most,  if  not  in  all  cases,  the  wedge-shaped  end 
of  the  inner  fragment  is  implanted  into  the  trochanteric  portion, 
producing  impaction. 

Adams'  arch,  the  densest  and  strongest  portion  of  the  neck, 
penetrates  the  deepest.  The  greater  the  inclination  of  the  inner 
fragment  forward,  the  more  extensive  the  impaction.  As  a  neces- 
sary result  of  this  impaction,  the  head  of  the  femur  descends  and 
approaches  the  posterior  inter-trochanteric  line;  the  dislocation  of 
the  head  in  these  directions  satisfactorily  accounts  for  the  shortening 
and  outward  rotation  of  the  limb. 

Accurate  statistics  as  to  the  frequency  with  which  impacted 
fractures  occur  as  compared  with  non-impacted  fractures,  are  still 
wanting.  The  individual  experiences  of  surgeons  are  so  widely  at 
variance  on  this  point,  that  a  final  decision  can  only  be  rendered 
after  the  accumulation  of  more  positive  knowledge  from  accurate 
bedside  observation  and  post-mortem  examinations. 

From  a  study  of  the  literature  on  this  subject  it  is  apparent, 
however,  that  the  more  recent  authors  advance  the  opinion  that  it  is 

1  Lehrbuch  der  Speciellen  Chirurgie,  B.  II.,  1879,  S.  837. 


IMPACTED   FRACTURES.  35 

of  frequent  occurrence.  It  is  also  evident  that  impaction  is  not 
limited  to  any  particular  part  of  the  femoral  neck,  but  that  it  can 
follow  any  fracture,  although  the  most  favorable  conditions  for  its 
occurrence  are  found  at  either  extremity  of  the  femoral  neck.  The 
direction  and  extent  of  impaction  depend  on  the  density  of  the 
tissues  which  are  penetrated,  and  on  the  direction  and  intensity  of 
the  fracturing  force.  Impacted  fractures  within  the  capsule  may 
occur  from  the  application  of  indirect  violence,  as  the  capsular  liga- 
ment will  offer  the  necessary  resistance;  on  the  other  hand,  impacted 
fractures  without  the  capsular  ligament  can  only  take  place  from 
direct  violence. 

It  is  also  possible  in  cases  of  this  kind,  as  suggested  by  several 
authors,  that  a  simple  fracture  is  produced  in  the  first  place  by  force 
applied  through  the  axis  of  the  femur,  and  impaction  takes  place 
subsequently  by  a  fall  upon  the  trochanter  major.  Impaction  from 
indirect  violence  would  necessarily  take  place  at  the  lower  portion  of 
the  constricted  portion  of  the  neck,  by  the  apex  of  the  femoral  brace 
penetrating  the  soft  spongiosa  of  the  head;  while  if  produced  by  a 
fall  upon  the  trochanter  major,  the  compacta  of  the  posterior  surface 
is  also  implanted  into  the  head.  Impaction  outside  of  the  capsule, 
from  the  normal  position  of  the  neck  and  the  direction  of  the  frac- 
turing force,  always  takes  place  at  the  expense  of  the  posterior 
portion  of  the  neck,  except  in  cases  where  the  fracturing  force  is  so 
severe  as  to  drive  the  entire  neck  wedge-like  into  the  upper  portion 
of  the  femoral  shaft,  splitting  the  latter  into  two  or  more  frag- 
ments. 

Impaction  implies  the  destruction  or  crushing  of  more  or  less  of 
bone  tissue;  and,  in  case  the  fragments  are  unlocked,  a  vacuum  is 
formed,  which  must  be  filled  by  the  interposition  of  fluids  or  the 
adjacent  soft  tissues.  It  is  well  known  that  intra-capsular  fractures 
are  often  produced  by  very  slight  injuries,  and  it  is  equally  certain 
that  these  are  the  cases  which  furnish  the  most  unfavorable  pros- 
pect s  for  a  good  result,  and  the  question  might  naturally  arise: 
Had  the  violence  been  sufficient  to  produce  deep  penetration,  would 
it  not  have  enhanced  the  prospects  for  a  more  favorable  issue?  In 
fractures  of  the  neck  of  the  femur  the  prospects  for  a  favorable 
result  are  better  if  the  exciting  cause  acts  with  sufficient  intensity  to 
produce  impaction,  as  this  condition  is  the  most  favorable  for  repair 
by  bony  union. 


36  EXPERIMENTAL   SURGERY. 

VIII.    Predisposing  Causes. 

Fracture  of  the  neck  of  the  femur  is  one  of  the  rarest  accidents 
during  childhood  and  adult  life,  while  after  the  fiftieth  year  it 
constitutes  a  high  percentage  of  all  fractures.  Between  the  ages 
of  twenty-one  and  thirty  it  constitutes  one-ninety-first  of  all  frac- 
tures; between  thirty  and  forty,  one-seventy-fourth  (Gurlt1);  between 
fifty  and  sixty,  nearly  one-tenth;  and  over  seventy,  one-third.  Its 
frequency  increases  steadily  with  the  advance  of  old  age.  A  num- 
ber of  theories  have  been  advanced  to  explain  this  clinical  fact. 

Thus,  Richter"  mentions  the  following  predisposing  causes: 
1.  Spongy  texture  of  neck,  and  diminution  in  thickness  of  compact 
layer.  2.  Diminution  in  the  obliquity  of  the  neck.  3.  Prominence 
of  trochanter  major,  by  which  the  fracturing  force  is  transmitted 
directly  to  the  neck. 

Walther3  assigns  to  syphilis  an  important  part.  Sex  has  also 
been  mentioned  as  a  predisposing  cause;  aged  females  furnish  a 
greater  number  of  fractures  than  aged  males,  and  it  was  claimed 
that  this  could  be  explained  by  the  more  horizontal  position  of  the 
neck  in  the  former  than  in  the  latter.  As  the  strength  of  the  femo- 
ral neck  is  derived  from  the  peculiar  architectural  arrangement  of 
the  spongiosa,  the  simple  diminution  of  its  angle  would  not  render 
it  more  liable  to  fracture,  as  Julius  Wolff  has  shown  that,  even  in 
fractures  that  have  healed  with  considerable  deformity,  the  structure 
of  the  spongiosa  is  perfectly  restored  in  accordance  with  the  original 
plan.  If  the  neck  is  placed  at  a  right  angle  to  the  shaft,  it  would 
give  way  more  easily  at  the  constricted  portion  on  the  application  of 
indirect  violence,  while  from  a  mechanical  standpoint,  it  ought  to 
resist  force  more  advantageously  in  case  it  is  applied  in  the  direction 
of  the  axis  of  the  neck. 

The  predisposing  cause  is  intrinsic,  inherent  in  the  bone  itself, 
a  degeneration  or  diminution  of  bone-tissue.  All  influences  which 
affect  nutrition,  and  that  of  bone  in  particular,  as  insufficient  or 
improper  food,  wasting  diseases,  prolonged  confinement  in  bed,  etc., 
hasten  the  degeneration  of  bone,  consequent  upon  senile  marasmus. 
Senile  osteo-porosis  then  is  the  only  known  predisposing  cause;  this 
assertion  is  abundantly  confirmed  by  clinical  experience. 

1  Handbuch  der  Lehre  von  den  Knochenbrueche,  1862,  vol.  i.,  p.  30. 

2  Lehrbuch  von  den  Bruechen,  etc.,  1833. 

3  System  der  Chirurgie,  1852.     B.    VI.,    S.  348. 


EXCITING   CAUSES.  37 

IX.    Exciting  Causes. 

Fractures  of  the  neck  of  the  femur  are  produced  by : 

1.  Force  applied  in  a  vertical  direction  through  the  axis  of  the 
femur. 

2.  Force  applied  in  a  horizontal  direction  over  the  trochanter 
major  in  the  axis  of  the  femoral  neck. 

3.  Traction  force  transmitted  through  the  capsular  ligament 
when  the  limb  is  forcibly  hyper-extended  and  adducted  and  rotated 
outward. 

A  fall  upon  the  foot  or  knee,  as  a  rule,  will  fracture  the  neck  at 
its  narrowest  portion.  If  the  fracture  is  complete,  no  impaction  will 
take  place,  unless  it  follows  as  a  secondary  occurrence  from  trans- 
mission of  force  through  the  trochanter  major.  Most  authorities 
who  believe  that  intra-capsular  fractures  are  the  most  frequent, 
assert  that  indirect  violence  is  the  most  frequent  exciting  cause. 

Experiments  and  clinical  observation  have  shown  that  the 
majority  of  fractures  of  the  neck  are  produced  by  force  applied  in 
the  direction  of  the  axis  of  the  neck  by  falls  upon  the  trochanter 
major.  It  is  also  an  established  fact  that  in  most  instances  of  this 
kind  the  neck  gives  way  at  its  trochanteric  portion,  and  that  the 
posterior  wall  is  crushed  or  fractured  first.  Impaction  takes  place 
more  frequently  from  direct  force,  with  deeper  penetration  of  the 
posterior  than  the  anterior  wall  of  the  neck. 

Of  thirty  cases  of  fracture  of  the  neck  examined  by  Desault1 
for  the  purpose  of  learning  the  exciting  cause,  twenty-four  were 
produced  by  a  fall  upon  the  trochanter  major.  All  the  cases 
reported  by  Sabatier  appear  to  have  been  produced  in  a  similar 
manner.  Sabatier  ascribed  to  the  prominence  of  the  greater  tro- 
chanter an  important  part  in  the  production  of  fracture,  and  believed 
that  fracture  of  the  femoral  neck  does  not  occur  in  children  on 
account  of  the  imperfect  development  of  the  upper  extremity  of  the 
femur. 

Although  direct  force  through  the  axis  of  the  neck  generally 
expends  itself  near  the  femoral  shaft,  causing  a  fracture  of  the 
expanded  portion  of  the  neck  with  posterior  impaction,  there  are  a 
number  of  cases  recorded  where  the  fracture  occurred  within  the 

1  A  Treatise  on  Fractures,  etc.,  1817. 


38  EXPERIMENTAL   SURGERY. 

capsule.     Intra-capsular  fractures  produced  in  this  manner  are  often 
impacted. 

The  last  manner  in  which  a  fracture  of  the  femoral  neck  may 
be  produced  is  by  forcible  hyper- extension  and  rotation  outward  of 
the  limb,  movements  by  which  the  ilio-femoral  ligament  is  put  upon 
its  utmost  stretch ;  and,  when  this  bone  has  become  so  fragile  that  it 
is  unable  to  resist  the  traction  of  this  powerful  ligament,  a  fracture, 
the  so-called  traction  fracture,  takes  place  at  the  junction  of  the 
neck  with  the  femoral  shaft.  This  fracture  is  always  extra -capsular, 
and  was  first  described  by  Linhart,  and  subsequently  experimentally 
studied  by  Rtidinger.1  The  latter  believes  the  fracture  takes  place 
before  the  patient  falls  upon  the  ground;  comminution  of  the 
trochanter  major  and  impaction  may  subsequently  result  from  direct 
violence. 

X.     Senile  Osteo-Porosis. 

Senile  osteoporosis  is  an  affection  of  the  bones  in  the  aged, 
characterized  by  diminished  elasticity  and  increased  fragility  as 
compared  with  healthy  bones.  It  is  an  excentric  atrophy  of  bone, 
due  to  impairment  of  the  physiological  functions  which  preside  over 
digestion  and  assimilation.  During  the  incipient  stages  the  bone 
retains  its  volume,  but  loses  in  density  and  weight,  owing  to  an  actual 
loss  of  bone-tissue,  which  necessarily  results  in  increased  porosity. 
This  affection  appears  first  in  the  spongiosa  of  the  head  and  neck 
of  the  femur,  and  it  is  here  where  its  most  advanced  stages  are 
observed.  In  the  upper  end  of  the  femur  this  senile  degeneration 
weakens  the  support  to  vertical  pressure,  allowing  the  head  gradually 
to  descend  in  some  instances  below  the  summit  of  the  great  trochan- 
ter, at  the  same  time  diminishing  the  oblique  angle  of  the  neck  to 
almost  a  right  angle  with  the  shaft. 

Senile,  in  connection  with  this  subject,  however,  is  a  relative 
term,  as  this  condition  of  the  bones  may  be  found  in  compara- 
tively young  people,  provided  senile  marasmus,  the  atrophic  changes 
peculiar  to  old  age,  from  any  cause  manifests  itself;  and,  on  the 
other  hand,  even  very  old  people,  when  otherwise  in  good  health,  may 
remain  exempt  from  this  form  of  senile  degeneration.  I  have  in  my 
possession  a  femur,  taken  from  a  gypsy  one  hundred  and  four  years 

1  Studien  tiber  Grand  u.  Einkeilung  d.  Schenkelhalsbrueche,  1874,  p.  63. 


SENILE   OSTEO-POROSIS.  39 

of  age  at  the  time  of  his  death,  which  illustrates  this  assertion.  The 
neck  of  the  bone  retains  the  normal  obliquity,  the  compact  layer  is 
firm  and  thick,  while  the  spongiosa,  although  somewhat  more  porous, 
presents  the  different  systems  of  arches  in  a  degree  of  perfection 
unsurpassed  at  any  age.  Senile  atrophy  of  bone,  and  the  diminu- 
tion in  the  obliquity  of  the  neck  of  the  femur  resulting  from  it,  have 
justly  received  so  much  attention  on  the  part  of  pathologists  and 
surgeons,  to  explain  the  frequency  of  fracture,  that  I  may  be  par- 
doned for  entering  more  fully  into  a  consideration  of  this  subject. 

All  authorities  agree  that  the  structural  degeneration  of  the 
neck  of  the  femur  is  an  important,  if  not  the  only  predisposing 
cause  in  the  production  of  fractures  in  this  locality  in  the  aged. 
The  increased  brittleness  of  bones  during  advanced  age  has  been 
explained  in  different  ways.  Bichat  attributed  it  to  an  excess  of  the 
inorganic  constituents  of  the  bone,  with  a  corresponding  decrease  of 
the  organic  matter.  This  view  found  almost  universal  acceptance 
among  surgeons,  and  is  still  taught  in  many  of  our  text-books  on 
surgery. 

Henle  was  among  the  first  to  assert  that  the  fragility  is  not 
caused  by  a  disproportion  of  the  earthy  and  organic  constituents  of 
bone,  but  that  it  is  the  result  of  an  actual  loss  of  bone  tissue,  a 
genuine  atrophy  of  bone.  Ribbert1  has  made  special  inquiries  into 
the  pathology  of  senile  atrophy  of  bone,  and  from  the  prevalence  of 
this  affection  along  the  lower  regions  of  the  Rhine,  he  has  been 
enabled  to  study  this  process  under  the  most  favorable  circumstances. 
On  examining  sections  of  osteo-porotic  bone  stained  with  carmine, 
he  invariably  found  osteoid  red  zones  upon  the  surface  of  the 
lamella,  varying  in  size,  extent,  and  number  in  proportion  to  the 
severity  of  the  process.  These  zones  presented  very  delicate  parallel 
lines,  and  bone-cells  with  very  fine  or  spindle-shaped  projections. 
The  margins  of  the  osteoid  layers  towards  the  unchanged  portion  of 
the  lamella  were  not  very  irregular,  and  were  usually  devoid  of 
lacumr.  Tlic  medulla,  as  a  rule,  was  pulpy,  hypersemic,  and  often 
infiltrated  with  Mood,  the  medullary  spaces  dilated,  and  Hie  lamellse 
correspondingly  reduced  in  thickness.  In  one  case  he  found  the 
latter  completely  destroyed  and  converted  into  osteoid  tissue,  form 
ing  cyst  like  cavities  tilled  with  pulpy  medullary  tissue. 

1  Ueber  senile  Osteo-m!il;ici;i  u.  Knochenresorption  im  Allgemeinen. 
ArHiiv.  f.  Path.  Aiiiit.,  LXXX.  S.  436. 


40  EXPERIMENTAL   SURGERY. 

Ribbert  regards  the  process  as  being  due  to  an  impairment  of 
nutrition,  which  of  necessity  is  attended  by  chemical  changes  of  the 
basis-substance  of  the  bone,  which  is  followed  again  by  a  separation 
of  the  earthy  phosphates  from  the  basis-substance.  The  earthy  salts 
are  rendered  soluble  by  acids  (perhaps  carbonic  acid)  contained  in 
the  fluids  of  the  body.  As  an  evidence  that  the  earthy  phosphates 
are  separated  from  the  organic  tissues,  the  author  mentions  that 
he  has  seen  "a  granular  opacity  at  the  junction  of  the  osteoid  spaces 
with  the  normal  bone,  which  cleared  up  on  the  application  of  an 
acid. 

Insufficient  or  improper  food  has  an  important  influence  in 
impairing  the  nutrition  of  bone,  as  has  been  abundantly  shown  by 
reliable  observations.  Roloff  *  made  experiments  on  animals  for  the 
purpose  of  studying  the  pathology  of  fragility  of  bones.  He  was 
able  to  produce  this  condition  artificially  by  depriving  the  animals 
of  all  food  containing  phosphate  of  lime.  He  ascribes  the  condi- 
tion primarily  to  a  diminution  of  the  earthy  constituents  of  bone; 
during  the  more  advanced  stages  of  decalcification  a  metamor- 
phosis of  osteoid  into  myeloid  tissue  takes  place.  The  walls  of 
the  canaliculi  appear  more  transparent  and  wider,  and  present  the 
appearance  of  light  stripes  with  dark  edges.  The  walls  of  the  bone- 
cells  or  spaces  become  translucent.  During  the  further  progress  of 
the  metamorphosis  the  appearances  are  such  as  would  indicate  that 
the  bony  tissue  over  greater  or  less  areas  had  been  entirely  destroyed, 
and  its  space  filled  up  with  new  myeloid  cells  from  the  adjacent 
myeloid  spaces.  A  close  examination,  however,  showed  that  the 
myeloid  cells  originated  from  the  bone  cells. 

Maresch  observed  an  epidemic  of  fragility  of  bones  among  cattle 
and  pigs  in  Bohemia,  which  lasted  for  three  years,  and  was  attribut- 
able to  a  prolonged  drouth  and,  consequent  upon  it,  poor  quality  of 
food.  He  invariably  found  that  the  disease  showed  a  predilection 
for  the  extremities  of  the  long  bones,  which  were  softened  to  such  an 
extent  that  they  could  be  readily  cut  with  the  knife.  The  interior  of 
the  spongiosa  was  filled  with  a  white  pultaceous  mass,  while  the 
compacta  was  reduced  to  a  thin  shell. 

M.  Mercier  observed  that  in  all  specimens  of  senile  atrophy  the 
alveolar  spaces  were  enlarged,  rendering  the  tissue  more  porous. 

1  Ueber  Osteo-malacia  u.  Rachitis.  Virchow's  Archiv,  B.  XXXVII.  Hft.  4, 
S.  434. 


SENILE   OSTEOPOROSIS.  41 

Kolliker1  believes  that  giant-cells  are  the  agents  which  produce 
absorption  of  bone  in  normal  and  pathological  conditions.  These 
cells,  when  found  in  bone,  he  calls  osteo-klasts.  They  originate  from 
osteo-blasts,  and  are  found  on  the  surface  and  in  the  interior  of  the 
lacunas. 

Humphry,2  in  mentioning  the  causes  of  fracture  of  the  femoral 
cervix,  alludes  to  the  subject  as  follows:  "In  the  aged  the  arrange- 
ment of  the  cancelli  which  in  the  young  and  middle-aged  are  so 
admirably  adapted  to  support  superimposed  weight,  becomes  imper- 
fect from  senile  degeneration,  a  process  which  begins  earliest  in  the 
upper  end  of  the  femur." 

Herman  Meyer3  advanced  the  idea  that  senile  osteo-porosis 
appears  under  the  form  of  a  non-suppurating  periostitis,  the  product 
of  which  as  yet  remains  unknown. 

Gurlt's*  description  of  senil^  osteo-porosis  may  be  condensed 
as  follows :  The  medullary  canal  is  enlarged,  the  cortical  layer  very 
thin  or  entirely  absent,  and  the  spongiosa  exceedingly  porous,  the 
meshes  being  filled  with  myeloid  tissue  of  a  dark  color. 

Kassowitz J  affirms  that  absorption  of  bone  takes  place  as  a  con- 
sequence of  increased  vascularization,  the  loss  of  bone-tissue  being 
the  direct  result  of  absorption. 

G.  Pommer''  has  studied  the  process  of  resorption  in  diseased 
bones  with  a  view  to  determine  the  formation  of  Howship's  depres- 
sions, and  the  function  of  the  osteo-klasts.  His  observations,  based 
upon  thirty  cases  of  bone  atrophy,  due  either  to  old  age  or  pressure 
from  any  cause,  has  induced  him  to  accept  Kolliker' s  views  as  men- 
tioned above. 

Morisane  has  made  histological  examinations  to  ascertain  the 
minute  processes  which  take  place  in  the  destruction  and  absorption 
of  bone  in  cases  of  rarefying  osteitis.  He  believes  that  the  normal 
exudation  which  takes  place  from  the  minute  vessels  in  bone  in  a 
state  of  health,  is  destined  to  perform  the  essential  part  in  the  pro- 

1  Die  Verbreitung  and  Bedeutung  d.  veilkernigen  Zellen  d.  Knoehen  u. 
Zaehne.     Virchow  u.  Hirsch  Jahresb.,  vol.  i,  1872,  p.  21. 
^Treatise  on  the  Human  Skeleton,  1871,  p.  471. 
'Op.  cit. 

4  Handbuch  von  der  Lehre  der  Knochenbruechen,  vol.  i,  1801. 

5  Virchow  u.  Hirseh's  Jahresberioht,  vol.  i.  1881,  p.  262. 

(i  Uebcr  die  lacunaere  Resorption  im  erkrunkten  Knoehen,  Weiner  Sitzungs- 
bericht,     B.  8.'{,  Abth.  III.  S.  17. 


42  EXPERIMENTAL  SURGERY. 

i 

duction  of  bone,  but  when  inflammation  is  present,  chemical  changes 

take  place  in  the  exuded  material,  which  annihilate  the  bone-produ- 
cing properties  of  the  cells.  He  distinguishes  an  acute  and  chronic 
form  of  the  disease.  In  the  chronic  form  the  destruction  of  the 
compact  tissue  is  the  result  of  a  progressive  diminution  of  its  earthy 
phosphates,  during  which  the  basis -substance  is  reduced  to  fibrillse, 
which  unite  with  the  connective  tissue  of  the  marrow  spaces,  and 
undoubtedly  materially  assist  in  the  formation  of  the  connective 
tissue  framework  of  these  spaces.  In  the  acute  form,  where  nutri- 
tion is  seriously  impaired,  the  stroma  undergoes  rapid  granular 
degeneration,  while  the  earthy  salts  are  absorbed,  the  bone-cells 
being  destroyed  instead  of  being  converted  into  connective  tissue,  as 
is  the  case  in  the  chronic  form.  In  the  chronic  as  well  as  the  acute 
variety  of  rarefying  osteitis,  the  death  and  absorption  of  bone -tissue 
is  dependent  in  an  intimate  manaer  on  the  numerical  increase  and 
degree  of  dilatation  of  the  small  vessels;  and,  to  a  certain  extent,  it 
also  results  from  a  chemical  change  which  the  products  of  exudation 
have  undergone;  to  this  latter  must  be  assigned  an  important  role 
as  a  dissolving  agent. 

I  have  called  attention  to  inflammatory  osteo-porosis  of  bone 
under  the  head  of  senile  osteo-porosis,  in  order  to  explain  the  rapid 
absorption  which  takes  place  after  fracture  of  the  neck  of  the  femur. 
In  all  of  these  cases,  and  more  particularly  in  the  intra-capsular 
variety,  more  or  less  of  the  neck  is  removed  by  absorption,  in  some 
instances  almost  the  entire  neck  disappears.  This  process  of 
absorption  after  fracture  expends  itself  more  on  the  lower  than  the 
upper  fragment,  and  more  upon  the  posterior  than  the  anterior  por- 
tion of  the  neck.  Interstitial  absorption  of  the  neck  of  the  femur 
in  young  adults,  as  described  by  Gulliver,1  can  only  be  explained  on 
the  hypothesis  that  inflammatory  softening  and  absorption  are 
induced  by  traumatism.  Only  in  two  cases  of  the  four  reported,  by 
Gulliver  was  the  diagnosis  verified  by  the  autopsy.  Both  were  young 
men  who  had  suffered  contusion  of  the  hip  on  the  affected  side;  in 
both  the  neck  was  shortened,  and  almost  at  a  right  angle  with  the 
shaft;  in  one  of  them  the  cancellated  tissue  of  the  neck  was  more 
compact,  and  some  adventitious  bony  material  on  its  surface  near 
the  shaft;  while  in  the  other  case,  "the  cancelli  of  the  neck  were 

1  Interstitial  Absorption  of   Neck  of   Femur  without   Fracture,  Medico- 
Chirurgical  Review,  vol.  xvii.,  p.  543. 


SENILE    0STE0-P0R0S1S.  43 

tilled  with  caseous  matter,  in  some  nearly  colorless,  in  others  tinged 
with  dark  grumous  blood."  • 

Similar  specimens  have  been  brought  forward  as  cases  of  bony 
union  after  intra-capsular  fracture;  there  is,  however,  in  all  of  these 
cases  a  symmetrical  atrophy  of  the  anterior  and  posterior  portion  of 
the  neck  of  the  femur,  while  in  cases  of  intracapsular  fracture  with 
bony  union,  there  is  almost  without  exception  a  greater  loss  of 
substance  of  the  posterior  than  of  the  anterior  portion  of  the  neck. 

Interstitial  absorption  of  the  neck  in  young  adults  is  always  the 
result  of  rarefying  osteitis,  which  eventuates  in  loss  of  bone-tissue; 
but  after  the  disease  has  subsided  regeneration  takes  place,  the 
spongiosa  becomes  more  dense  by  deposit  of  new  bone,  while  the 
same  process  takes  place  beneath  the  periosteum,  giving  rise  to 
adventitious  bone,  which  might  easily  be  mistaken  for  callus,  as  in 
Case  3  described  by  Gulliver;  in  other  instances  the  process  of 
destruction  is  not  followed  by  repair,  the  products  of  inflammation 
remain  in  the  cancelli,  as  in  Case  4  mentioned  by  the  same  author. 

There  has  been  considerable  difference  of  opinion  in  regard  to 
the  particular  structure  which  is  the  primary  or  most  important  seat 
of  senile  osteoporosis.  Authors  have  located  it  in  the  structures 
which,  in  accordance  with  the  views  they  entertained,  were  supposed 
to  furnish  the  principal  support  to  vertical  pressure:  thus  Meyer 
found  it  in  the  spongiosa,  Merkel  in  the  calcar  femoral,  Bigelow  in 
the  compact  tissue  of  the  neck.  Senile  degeneration,  in  preference, 
affects  the  spongy  bones,  and  the  spongy  portions  of  the  long  bones ; 
hence,  there  can  be  no  doubt  that  it  first  attacks  the  spongiosa  in 
the  interior  of  the  head  and  neck  of  the  femur,  from  which  it  grad- 
ually invades  the  different  parts  of  the  compact  tissue. 

In  order  to  prove  this  assertion  I  have  examined  a  number  of 
sections  of  the  upper  extremity  of  the  femur  from  persons  advanced 
in  years,  and  have  repeatedly  observed  the  spongiosa  atrophic  and 
porous,  while  the  femoral  brace  and  the  calcar  femoral  retained 
their  normal  strength.  During  the  advanced  stage  of  the  affection 
the  compacta  may  be  reduced  to  the  thinness  of  paper,  or  disappear 
entirely,  the  periosteum  coming  in  contact  with  the  spongiosa;  in 
such  cases,  fracture  takes  place  on  the  slightest  application  of  force, 
and  the  bone  can  be  readily  cut  with  a  knife.  The  myeloid  spaces 
are  the  starting  points  of  the  process  of  degeneration;  they  are 
enlarged  ami  become  distended  by  the  accumulation  of  myeloid  cells 


44  EXPERIMENTAL  SURGERY. 

and  granulation  tissue;  the  cancelli  are  broken  down,  and  thus  spaces 
of  considerable  size  are  created  at  the  expense  of  the  regular  system 
of  arches  which  make  up  the  structure  of  the  spongiosa. 

Giant  cells  and  granulation  tissue  possess  the  property  to  disin- 
tegrate and  absorb  bone;  they  are  the  destructive  agents,  while  the 
broken-down  tissue  is  removed  by  the  blood-vessels.  When  sections 
of  a  bone,  the  seat  of  senile  atrophy,  are  examined  during  the  earlier 
stages  of  the  process,  they  present  a  vascular  and  red  appearance, 
on  account  of  increased  vascularization  and  an  abundant  deposit  of 
red  marrow.  When  degeneration  has  progressed  to  the  highest 
degree,  the  compacta  has  disappeared  almost  completely,  the  spon- 
giosa is  exceedingly  porous,  the  alveoli  large  and  filled  with  fat,  and 
the  bone  presents  a  yellow  appearance,  imparted  by  the  free  fat 
derived  from  the  fatty  degeneration  of  the  histological  elements. 

As  long  as  the  bone  is  supplied  with  an  abundance  of  myeloid 
tissue  and  blood-vessels,  its  bone-producing  capacity  is  not  impaired; 
on  the  other  hand,  it  is  said  to  be  increased,  irrespective  of  the 
degree  of  softening  and  fragility;  but  if  fatty  degeneration  has  pro- 
gressed to  the  extent  just  mentioned,  and  the  vascular  supply  is 
greatly  diminished,  as  is  the  case  in  the  most  aggravated  forms  of 
senile  osteo-porosis,  no  attempt  at  production  of  bone  can  reasonably 
be  expected  in  the  event  of  fracture.  We  are  then  justified  from  a 
consideration  of  the  foregoing  remarks  in  adopting  the  following 
conclusions : 

1.  Senile  osteo-porosis  is  the  only  predisposing  cause  of  frac- 
tures of  the  neck  of  the  femur  in  the  aged. 

2.  Senile  osteo-porosis,  except  in  the  most  advanced  stages 
of  fatty  infiltration,  does  not  impair,  but  hastens  the  production  of 
myeloid,  or  permanent  callus. 

XI.    Symptoms  of  Fracture  of  the  Neck  of  the  Femur. 

As  the  very  best  authorities  are  forced  to  admit  that  during  life 
it  is  impossible  to  locate  accurately  the  precise  seat  of  fracture,  there 
exists  no  longer  the  necessity  of  considering  the  symptoms  separately 
under  the  head  of  intra-  and  extracapsular  fracture.  In  practice, 
the  greatest  care  should  be  exercised  to  ascertain  the  presence  of 
impaction;  but  even  impacted  fractures  present  the  most  important 
symptoms  in  common  with  non-impacted  fractures;  and  they  may 


SYMPTOMS   OF  FRACTURE.  45 

be  conveniently,  and  I  think  profitably  grouped  together  to  prevent 
unnecessary  repetition. 

The  symptoms  presented  by  a  fracture  through  the  neck  of  the 
femur,  as  in  any  other  fracture,  are :  1.   Subjective;  2.  Objective. 

i.     Subjective  Symptoms. 

The  subjective  symptoms  are:  a,  Pain;  b,  Loss  or  impairment 
of  function. 

a.    Pain. 

The  pain  is  due  either  to  the  immediate  effects  of  the  trauma- 
tism, laceration  of  the  contiguous  soft  tissues,  irritation  produced  by 
the  movements  of  the  fractured  ends,  or  the  inflammation  of  the 
bone  or  surrounding  tissues  succeeding  the  injury.  The  pain  is 
variable,  almost  absent  and  of  short  duration  in  some  cases,  excru- 
ciating and  continuous  for  months  and  sometimes  years  in  others. 
If  the  fracture  is  located  in  the  narrow  portion  of  the  neck,  the  pain 
is  usually  referred  to  the  groin  about  the  insertion  of  the  ilio-psoas 
muscle;  if  at  or  near  its  base,  it  is  more  diffuse,  and  referred  to  the 
seat  of  injury. 

There  has  been  considerable  discrepancy  of  opinion  as  to  the 
severity  of  the  pain  in  fractures  within,  as  compared  with  fractures 
without  the  capsule.  Sir  Astley  Cooper  maintained  that  it  was  less 
severe  in  the  former  variety,  while  Malgaigne  claimed  that  the 
reverse  was  true.  As  fractures  of  the  narrow  portion  of  the  neck 
are  the  result  of  less  violence  than  those  occurring  near  the  shaft,  it 
is  undoubtedly  true  that  the  pain  attending  them  immediately  after 
the  traumatism  is  less  than  in  the  latter  class  of  injuries,  while  the 
reverse  may  be  true  during  the  subsequent  history  of  the  case.  In 
impacted  fractures,  where  the  favorable  conditions  for  bony  union 
are  not  disturbed,  and  the  process  of  repair  is  initiated  at  once,  and 
progresses  uninterruptedly,  the  pain,  as  a  symptom,  is  referable 
only  to  the  traumatism;  and  as  such,  is  more  severe,  as  a  rule,  in 
fractures  where  the  greatest  amount  of  tissue  has  been  lacerated, 
that  is,  in  extra-capsular  fractures. 

In  cases  of  non-impacted  fractures  within  the  capsule,  with 
motion  of  the  fragments  upon  each  other,  a  certain  amount  of 
inflammation  springs  up,  which  is  always  attended  by  its  most  promi- 
nent symptom,  pain.      When  pain,   the  result  of  inflammation,  is 


46  EXPERIMENTAL  SURGERY. 

present,  it  assumes  the  characteristic  features  as  witnessed  in  coxitis 
independent  of  fracture.  It  is  then  no  longer  a  symptom  of  fracture, 
but  indicates  the  accession  of  traumatic  coxitis.  The  presence  of  no 
inconsiderable  amount  of  inflammation  has  repeatedly  been  verified 
at  post-mortem  examinations,  in  the  form  of  thickening  of  the 
capsule,  adhesions,  and  destruction  of  the  synovial  membrane  and 
cartilage.  Any  attempt  at  motion  or  pressure  against  the  trochanter 
major  aggravates  the  pain.  In  some  old  inveterate  cases  the  pain 
assumes  a  neuralgic  type,  which  would  indicate  that  some  of  the 
nerves  about  the  hip -joint  were  encroached  upon  by  the  displaced 
fragments,  or  exuberant  callus,  or  the  products  of  inflammation. 

b.    Loss  or  Impairment  of  Function. 

This  symptom  is  present  in  all  fractures  of  the  femoral  neck. 
As  a  general  rule,  it  may  be  stated,  it  is  prominent  as  a  symptom  in 
proportion  to  the  degree  of  separation  of  the  fragments.  In  impacted 
fractures  the  patients  are  often  able  not  only  to  move  the  limb,  but 
even  to  walk  for  hours  and  sometimes  days.  The  impairment  of 
voluntary  movements  does  not  depend  alone  on  the  direct  loss  of 
support,  but  is  also  influenced  by  the  pain  incident  to  such  move- 
ments; hence,  this  symptom  will  present  itself  in  the  highest  degree 
in  nervous,  excitable  patients.  Laceration  of  the  soft  parts,  the 
periosteum,  and  capsule,  in  the  absence  of  impaction,  will  also 
counteract  voluntary  motion,  not  only  by  allowing  a  greater  degree 
of  disjunction  of  the  fragments,  but  likewise  by  increasing  the  pain 
on  any  attempt  at  motion. 

In  the  great  majority  of  cases  the  patient,  as  he  lies  in  bed,  is 
unable  to  raise  or  move  the  limb  in  any  direction;  it  remains  per- 
fectly helpless  in  the  position  it  was  left  after  the  accident,  or  in 
which  it  had  been  left  by  the  displacing  elements.  In  some  cases 
where  interlocking  of  the  fragments  exists,  or  where  a  slight  amount 
of  impaction  has  taken  place,  the  patient  has  control  over  a  certain 
amount  of  voluntary  movements  for  a  number  of  days,  or  until 
disjunction  of  the  fragments  takes  place  as  a  result  of  injudicious 
examination  or  inflammatory  osteo-porosis,  when  the  limb  is  placed 
in  the  same  conditions  as  if  no  impaction  had  taken  place. 

2.     Objective  Symptoms. 

The  objective  symptoms  are:  a.  Swelling  and  deformity  at  the 
hip.    b.  Suggillation  about  the  hip.    c.  Eversion  of  limb.    d.  Shorten- 


SYMPTOMS   OF  FRACTURE.  47 

ing.  e.  Change  of  position  of  trochanter  major.  /.  Increased  or 
diminished  mobility  of  the  hip-joint,  g.  Loss  of  tension  of  fascia 
lata  between  the  trochanter  major  and  the  crest  of  the  ilium. 

a.     Swelling-  and  Deformity. 

In  all  cases  there  is  an  appreciable  fnllness  in  the  fold  of  the 
groin  corresponding  to  the  seat  of  fracture.  This  swelling  is  caused 
by  the  hinge-like  projection  of  the  anterior  portion  of  the  neck, 
effusion  of  blood  or  inflammatory  products,  and,  lastly,  by  the  over- 
riding or  impaction  of  the  fragments.  When  impaction  takes  place 
at  the  base  of  the  neck,  the  trochanteric  portion  of  the  femur  is 
enlarged  from  implantation  of  the  upper  fragment.  The  swelling 
is  larger  when  the  fracture  is  located  without  the  capsule,  from  the 
more  extensive  bone  injury  and  the  more  copious  effusion  of  blood. 

b.     Sug-gillation . 

Suggillation  appears  earlier  and  more  constantly  the  nearer  the 
fracture  is  seated  to  the  femoral  shaft.  As  this  symptom  is  the  result 
of  the  presence  of  blood  at  the  point  of  fracture,  it  is  more  extensive 
if  the  haemorrhage  has  been  considerable  and  outside  of  the  capsule. 
If  the  haemorrhage  has  been  within  the  capsule,  and  the  capsule  is 
ruptured  at  some  point,  the  discoloration  will  usually  show  itself 
along  the  inner  side  of  the  thigh.  The  same  force  which  produced 
the  fracture  may  also  contuse  the  soft  parts  sufficiently  to  give  rise 
to  superficial  discoloration  independent  of  the  fracture. 

c.    Bversion. 

The  lower  limb  in  a  natural  condition  is  slightly  everted  on 
account  of  the  forward  obliquity  of  the  femoral  neck.  This  normal 
eversion  is  increased  during  sleep  when  the  muscles  are  at  rest,  or 
when  they  have  been  completely  relaxed  by  an  anaesthetic,  or  when 
their  action  has  been  permanently  suspended  by  paralysis.  In  the 
normal  condition,  then,  the  weight  of  the  limb  effects  outward  rota- 
tion until  arrested  by  muscular  action,  or  the  resistance  offered  by 
the  ligament  of  the  hip-joint.  As  the  posterior  wall  of  the  neck  is 
usually  the  seat  of  more  extensive  comminution  or  impaction  than 
the  anterior,  and  as  the  fracturing  force  in  the  majority  of  cases  is 
a])] died  in  the  antero-lateral  direction,  it  is  only  reasonable  to  expect 
outward  rotation  of  the  limb  to  be  the  rule.  This  expectation  has 
bftMi   verified  by   clinical  observation.     Until  recently  it  lias  been 


48  EXPERIMENTAL   SURGERY. 

generally  supposed  that  eversiori  is  the  result  of  muscular  contrac- 
tion, and  in  support  of  this  view  it  has  been  suggested  that  in  non- 
impacted  fractures,  it  increases  after  the  muscles  have  recovered  their 
contractility. 

Edmund  Owens,  on  the  ground  of  anatomical  demonstrations 
and  carefully  made  experiments,  as  well  as  accurate  clinical  observa- 
tion, holds  that  eversion  of  the  limb  takes  place  independently  of 
muscular  contraction,  that  it  is  invariably  the  result  of  the  impacting 
force  or  the  weight  of  the  limb,  as  the  case  may  be.  In  intra-capsu- 
lar  fractures  it  is  especially  true  that  eversion  is  more  marked  a  few 
days  after  the  injury,  but  this  fact  can  be  interpreted  more  satisfac- 
torily from  a  different  standpoint.  In  such  cases  the  fragments  are 
often  kept  in  apposition  by  an  interlocking  of  the  broken  surfaces  or 
unlacerated  portions  of  the  fibrous  investment  of  the  neck;  either  of 
these  supports  may  give  way  to  the  constant  traction  from  the 
weight  of  the  limb,  or  the  same  result  may  take  place  from  reflex 
muscular  contractions,  or  careless  handling  of  the  limb.  After  the 
fracture,  the  great  mass  of  muscles,  the  external  rotators  of  the  hip, 
are  relaxed  from  the  approximation  of  their  points  of  origin  and 
insertion,  and  it  is  difficult  to  conceive  in  what  way  they  could  effect 
outward  rotation.  Dupuytren  believed  that  eversion  may  also  be 
due  to  the  action  of  the  adductor  muscles,  and  in  some  instances  to 
the  obliquity  of  the  fracture  itself. 

It  is  also  necessary  to  mention  that  eversion  is  not  a  constant 
symptom.  Cases  have  been  described  by  reliable  observers  where 
the  limb  remained  normal  so  far  as  the  position  of  the  foot  was  con- 
cerned, and  in  some  even  the  reverse,  inversion,  occurred.  Cases  of 
fracture  with  inversion  have  been  described  by  Ambroise  Par6,  J.  L. 
Petit,  Guthrie,  Stanley,  Dupuytren,  Desault,  Cruveilhier,  Hamilton, 
R.  W.  Smith,  and  others.  Desault  thought  that  it  occurred  in 
about  one  case  out  of  every  four.  Stanley  observed  one  case  where 
the  autopsy  showed  that  the  fracture  was  purely  intra-capsular, 
and  no  satisfactory  explanation  could  be  found  for  the  inversion. 

Wm.  Pirrie  mentions  a  case  of  intra-capsular  fracture  where 
the  limb  was  not  only  inverted  but  also  strongly  flexed  and  adducted, 
a  position  he  ascribed  to  the  tension  of  the  ilio-femoral  ligament. 
Of  the  one  hundred  and  thirty  cases  of  intra-capsular  fracture  of 
the  neck  of  the  femur  which  came  under  Pirrie's  observation,  and 
in  which  the  accuracy  of  the  diagnosis  was  verified  by  dissection, 


SYMPTOMS   OF  FRACTURE.  -40 

this  was  the  only  case  with  flexion,  adduction,  and  rotation  inward 
of  the  limb.  Of  the  remaining  number,  inversion  existed  in  only 
one  case,  the  limb  in  other  respects  occupying  the  usual  straight 
position. 

Malgaigne1  reports  an  exceedingly  interesting  case.  "In  1833, 
having  found  the  foot  inverted  in  a  fracture  of  the  neck  of  the 
femur,  I  ascertained  that  it  was  easily  everted  and  again  inverted  at 
will,  and  that  it  remained  as  readily  in  one  position  as  in  the  other; 
whence  I  concluded  that  whatever  inclination  is  given  to  the  part 
upon  the  supporting  plane  it  keeps  by  its  own  weight.'''''1  This 
observation  is  exceedingly  valuable,  and  would  lead  us  to  the  con- 
clusion that  whenever  the  support  derived  from  the  cervical  portion 
of  the  femur  is  lost,  the  limb  will  follow  the  natural  law  of  gravita- 
tion, and  will  turn  outward  by  its  own  weight,  unless  opposed  by 
some  special  conditions  at  the  seat  of  fracture,  or  by  external  influ- 
ences. 

d.    Shortening-. 

The  significance  of  shortening  as  a  symptom  of  fracture  of  the 
neck  of  the  femur  has  received  additional  interest,  since  it  has  been 
ascertained  that  frequently  there  is  a  natural  difference  in  the  length 
of  the  lower  extremities  in  the  same  individual.  Dr.  J.  S.  Wight, 
of  Brooklyn,  has  made  a  valuable  contribution  to  surgery  relating  to 
the  comparative  length  of  the  inferior  extremities  in  the  same  indi- 
vidual. His  first  published  table  comprised  the  measurements  of 
sixty  persons,  of  varied  nationalities,  pursuits  and  ages.  In  these  sixty 
there  were  ten  persons  who  presented  a  parity  of  length  in  the  two 
legs,  and  fifty  who  showed  a  difference  varying  from  one-fourth  of 
an  inch  to  one  and  three-eighths  inches.  The  right  leg  was  longer 
in  eighteen,  and  the  left  in  thirty -two  instances.  A  second  table 
comprises  forty-two  measurements,  and  shows  a  parity  of  length  in 
thirteen,  and  a  difference  in  twenty-nine  instances,  the  difference 
varying  from  one-fourth  of  an  inch  to  one  inch.  In  nine  cases  the 
right,  and  in  twenty  the  left  limb  was  the  longer.  Hamilton  has 
corroborated  these  statements  by  his  own  researches. 

Gurson3  has  made  some  further  investigations  which  tend  to 

1  A  Treatise  on  Fractures.     Translated  by  J.  H.  Packard,  M.D.,  p.  543. 

2  Italics  my  own. 

3  Inequality  in  Length  of  the  Lower  Limbs.  Journ.  of  Anat.  and  Phys., 
vol.  xiii,  p.  26. 

4 


50  EXPERIMENTAL  SURGERY. 

establish  the  correctness  of  these  observations.  He  examined  seventy 
skeletons  of  different  sexes  and  ages,  and  belonging  to  different 
races.  He  found  that  the  lower  extremities  were  of  the  same  length 
in  only  seven  of  this  number,  and  among  these  the  femur,  tibia  and 
fibula  were  of  the  same  length  on  both  sides  in  two,  while  in  the 
remaining  five  the  tibia  and  fibula  and  the  femur  equalized  the  dif- 
ference in  length.  In  54  per  cent,  of  the  cases  the  left  extremity 
was  longer  than  the  right,  the  average  difference  being  4.8  mm., 
and  the  maximum  difference  13  mm.  The  right  extremity  was  longer 
than  the  left  in  55.8  per  cent.,  with  an  average  difference  in  length 
of  3.3  mm.,  and  a  maximum  of  only  8  mm.  These  measurements 
not  only  prove  that  the  lower  limbs  differ  in  length  in  a  majority  of 
the  cases  examined,  but  they  likewise  point  out  the  importance  of 
measuring  the  long  bones  separately  for  the  sake  of  comparison, 
when  measurements  are  made  for  diagnostic  purposes. 

More  or  less  shortening  will  take  place  in  every  case  of  fracture 
of  the  neck.  M.  Lisfranc  and  M.  Lallemand1  each  have  reported 
a  case  where  the  limb  was  lengthened.  It  is  impossible  to  conceive 
in  what  manner  the  fracture  could  add  to  the  length  of  the  limb; 
still  the  observations  were  undoubtedly  correct,  and  an  explanation 
can  only  be  given  by  assuming  that  the  amount  of  actual  shortening 
was  slight,  and  that  the  patient's  limbs  were  of  unequal  length. 
The  amount  of  shortening  depends  on  the  degree  of  disjunction; 
the  greater  the  longitudinal  displacement,  the  greater  the  shortening. 
The  shortening  is  always  the  direct  result  of  muscular  contraction 
or  longitudinal  displacement  by  impaction.  In  impacted  fractures 
the  maximum  is  reached  at  once,  and  the  degree  of  shortening 
depends  on  the  depth  of  penetration  or  mutual  inter-penetration  of 
the  fractured  ends.  In  cases  of  impaction  the  shortening  remains 
stationary,  as  the  fracture  is  not  disturbed,  and  can  only  increase  on 
the  advent  of  inflammatory  interstitial  absorption. 

In  fractures  without  the  capsule,  all  resistance  to  muscular  con- 
traction is  lost,  and  the  maximum  amount  of  shortening  is  reached 
as  soon  as  the  muscles  have  become  contracted.  If  the  capsule  is 
intact,  and  remains  attached  to  the  lower  fragment,  shortening  takes 
place  gradually  by  stretching  of  the  capsular  ligament.  In  case  the 
fragments  are  held  in  contact  by  the  denticulated  fractured  surface, 

1  Dupuytren,  Injuries  and  Diseases  of  Bones. 


SYMPTOMS   OF  FRACTURE.  51 

shortening  can  only  proceed  after  this  medium  of  apposition  has 
been  removed  by  displacement  of  the  bones,  or  after  inflammatory 
osteo-porosis  has  removed  the  projecting  spicules.  This  condition  is 
often  met  with  in  intra-capsular  fractures.  The  degree  of  shorten- 
ing immediately  after  a  fracture  has  been  relied  upon  by  some  in 
determining  the  seat  of  fracture.  Among  surgeons  there  has  been, 
however,  such  discrepancy  of  opinion  in  this  respect,  that  no  reliable 
deductions  can  be  drawn  from  this  circumstance  in  rendering  a 
decision. 

Sir  Astley  Cooper  and  Amesbury  claim  the  greatest  shortening 
for  intra-capsular  fractures,  while  Stanley,  Earle,  and  R.  W.  Smith 
entertain  an  opposite  opinion.  Impaction  and  the  integrity  of  the 
capsular  ligament  are  such  important  factors  in  determining 
the  amount  of  shortening  and  the  time  when  it  takes  place,  that 
these  conditions  must  be  carefully  considered  in  estimating  the  value 
of  shortening  as  a  diagnostic  aid. 

e.    Change  of  Position  of  Trochanter  Major. 

The  trochanter  major  is  displaced  upward  and  backward,  in 
proportion  to  the  amount  of  shortening  and  eversion.  When  short- 
ening has  taken  place,  its  upper  border  has  passed  beyond  Nelaton's 
line.  When  the  limb  is  rotated,  it  describes  a  smaller  arc  of  a  circle. 
It  is  less  prominent  when  impaction  has  taken  place,  or  when  the 
lower  fragment  is  not  in  apposition  with  the  upper. 

f.    Alteration  of  Motion. 

A  false  point  of  motion  is  always  established  in  non-impacted 
fractures.  Preternatural  mobility  is  most  marked  if  the  fracture  is 
not  impacted  and  if  it  be  located  outside  of  the  capsule.  It  is 
probably  in  cases  of  this  kind  that  Gerdy  has  been  able  to  rotate  the 
limb  outward  until  the  toes  looked  backward,  and  that  Maisonneuve 
brought  into  requisition  his  test  of  hyper-extension.  If  the  fracture 
is  within  the  intact  capsule,  the  latter  will  serve  as  a  retentive  meas- 
ure, and  limit  the  motion  between  the  fractured  bones.  Dr.  Levis 
has  found  that  in  non-impacted  fractures  the  limb  can  be  extended 
beyond  its  normal  length.  In  case  Arm  impaction  has  taken  place, 
tlif  neck  has  become  shorter  and  thicker,  conditions  which  neces- 
sarily impair  the  natural  mobility  of  the  hip-joint. 


52  EXPERIMENTAL  SURGERY. 

g.    Fascia  Lata. 

Dr.  Allis,1  of  Philadelphia,  has  added  another  symptom,  which 
indicates  fracture  through  the  neck  of  the  femur,  namely,  the  exist- 
ence of  a  relaxed  condition  of  the  fascia  lata  between  the  crest  of 
the  ilium  and  the  trochanter  major  on  the  injured  side,  produced 
by  the  loss  of  resistance,  which  is  furnished  by  the  neck  when  not 
broken.  As  the  presence  of  this  symptom  depends  on  the  dislocation 
of  the  lower  fragment  upward  and  inward,  it  is  only  met  with  when 
such  changes  have  taken  place.  The  standing  position  is  the  only 
one  in  which  this  test  can  be  applied,  as  in  the  reclining  position 
the  muscles  that  make  tense  the  fascia  are  relaxed. 

Bezzi2  has  called  attention  to  a  sign  which  he  considers  as 
pathognomonic  of  fracture  of  the  neck  of  the  femur.  In  examining 
the  space  between  the  trochanter  and  the  crest  of  the  ilium,  it  will 
be  found  that  while  on  the  same  side  the  muscles  occupying  this 
region  (the  tensor  vaginae  f  emoris  and  gluteus  medius)  are  tense,  and 
offer  to  the  hand  a  considerable  feeling  of  resistance,  they  present 
on  the  affected  side  a  deep,  well-marked  depression,  flaccidity  and 
diminution  of  tension,  from  displacement  upward  of  their  points  of 
insertion.  This  sign  appears  under  the  same  circumstances,  and 
possesses  the  same  significance  as  the  one  described  by  Dr.  Allis. 

I  have  intentionally  omitted  to  mention  crepitus  as  a  symptom, 
as  more  harm  than  benefit  has  accrued  from  the  efforts  of  the 
anxious  surgeon  to  establish  a  positive  diagnosis  on  the  presence  or 
absence  of  this  sign.  A  careful  study  of  the  other  symptoms  will 
usually  enable  us  to  arrive  at  a  correct  conclusion,  without  exposing 
the  patient  to  the  risks  incident  to  the  manipulations  necessary  for 
the  purpose  of  eliciting  this  symptom. 

XII.    Diagnosis. 

All  manipulations,  during  the  examination  of  a  supposed  frac- 
ture through  the  cervix  femoris,  should  be  performed  with  the 
utmost  care  and  gentleness.  The  so-called  "  thorough  examination," 
the  search  for  positive  symptoms,  has  been  the  source  of  incalculable 
mischief.      In  many  instances  careless  handling  of  the  limb  has 

1  Mechanism  of  the  Hip-Joint.     Med.  &  Surg.  Reporter,  vol.  xxxvi.,  p.  303. 

2  Centralbl.  fur  Chirurgie,  July  31,  1880. 


DIAGNOSIS.  53 

resulted  in  the  disjunction  of  impacted  fractures,  or  in  the  tearing 
of  periosteal  or  ligamentous  bands,  thus  precluding  most  effectually 
possible  union  by  bone  or  the  formation  of  a  short  fibrous  union. 
Years  ago,  Davis '  entered  his  protest  against  such  reckless  examina- 
tions in  the  following  emphatic  manner:  "Now,  while  we  willingly 
concede  the  importance  of  a  correct  diagnosis  in  its  bearings  upon 
the  successful  treatment  of  any  case,  we  hold  that  too  much  hand- 
ling and  manipulation  of  the  limb  in  intracapsular  fracture  is  liable 
to  eventuate  in  irreparable  injury  to  the  patient."  Again:  "When 
this  connecting  link  of  periosteum  and  capsular  ligament  is  not 
severed  by  officious  handling  on  the  part  of  the  surgeon,  in  his  zeal- 
ous, but  often  mischievous  efforts  to  ascertain  to  the  fullest  extent 
the  details  of  the  injury,  then  we  may  hope  for  better  results  than 
have  usually  followed  this  accident." 

Bryant's"  caution  is  equally  strong:  "In  fact  the  ordinaiy  frac- 
ture of  the  base  of  the  neck  of  the  thigh-bone  is  primarily  an 
impacted  fracture,  the  impacted  bone  in  some  cases  being  loosened 
by  a  second  fall,  in  others  by  excess  of  violence  received  in  the  origi- 
nal accident,  and  in  too  many  by  the  manipulations  of  the  surgeon 
in  his  anxiety  to  make  out  the  presence  of  a  fracture  by  the  detection 
of  crepitus.  Indeed,  this  seeking  for  crepitus  in  cases  of  fracture  is 
a  practice  fraught  with  danger." 

I  shall  not  allude  to  crepitus  as  a  diagnostic  sign,  as  a  satisfac- 
tory diagnosis  can  usually  be  made  without  it,  by  a  careful  consid- 
eration of  the  other  symptoms.  In  every  case  of  suspected  fracture 
\v<*  should  make  careful  search  for  evidences  of  senile  osteoporosis, 
and  ascertain  as  nearly  as  possible  the  amount  of  force  applied,  and 
the  direction  in  which  it  was  applied.  If  the  general  appearance  of 
the  patient  indicates  the  existence  of  far-advanced  senile  osteo- 
porosis, the  amount  of  force  has  been  slight;  and  if  inflicted  in  the 
direction  of  the  axis  of  the  thigh-bone,  it  is  more  than  probable  that 
the  fracture  has  occurred  within  the  capsule.  If  the  fracturing 
force  has  been  greater,  and  applied  transversely  in  the  axis  of  the 
femoral  neck,  we  have  reason  to  expect  that  the  fracture  has  taken 
place,  at  Least  partly,  without  the  capsule. 

The  sudden  and  complete  loss  of  function  of  the  limb  after  an 
injury  to  the  hip  in  a  person  over  fifty  years  of  age  speaks  strongly 

1  Conservative  Surgery,  L867,  p.  23. 

*  Bryant's  Practice  of  Surgery.     Edited  by  J.  B.  Roberts,     p.  842. 


54  EXPERIMENTAL   SURGERY. 

in  favor  of  a  fracture  through  the  femoral  neck.  We  can  say  with 
Hodgson:  "If  an  elderly  person,  after  a  fall  upon  the  hip,  is  unable 
to  use  the  injured  limb,  it  is  very  probable  that  a  fracture  of  the 
neck  of  the  femur  has  been  sustained,  and  this  is  more  likely  to  be 
the  case,  if,  during  the  fall,  no  such  great  force  has  acted  upon  the 
greater  trochanter  as  would  be  necessary  to  produce  a  contusion 
sufficiently  severe  to  render  the  limb  useless." 

Aside  from  a  general  consideration  of  the  case,  the  diagnosis 
will  depend  on  the  presence  or  absence  of  the  two  most  important 
symptoms,  shortening  and  eversion.  Many  of  our  best  surgeons 
depend  almost  exclusively  on  accurate  measurements  in  rendering  a 
diagnosis.  The  amount  of  immediate  shortening  will  vary  according 
to  the  presence  or  absence  of  impaction,  from  a  few  lines  to  two 
inches.  In  impacted  fractures  the  shortening  is  immediate,  and 
remains  stationary  unless  displacement  takes  place,  or  during  the 
reparative  process,  the  femoral  neck  is  shortened  by  interstitial 
absorption.  The  progressive  shortening,  a  few  days  after  the  acci- 
dent, is  due  to  a  loosening  of  the  fragments  which  have  been  in 
mutual  contact  by  denticulated  projections,  and  to  a  gradual  stretch- 
ing of  untorn  portions  of  the  capsular  ligament.  Mr.  Bryant,  in 
speaking  of  the  utility  of  his  "test-line,"  says:  "Indeed,  as  a  proof 
of  its  use,  I  may  add  that  twenty-five  consecutive  cases  of  fracture 
of  the  neck  of  the  thigh-bone,  admitted  into  my  wards  to  the  end  of 
1877  (the  average  age  of  the  patients  being  seventy-four),  left  the 
hospital  with  union  of  the  broken  bones  and  useful  limbs." 

Dr.  J.  S.  Wight,  of  Brooklyn,  has  written  an  exceedingly 
interesting  and  practical  paper  on  diagnosis  of  fractures  of  the 
femoral  neck,  based  on  the  report  of  twenty-one  cases.1  For  the 
purpose  of  avoiding  errors,  which  might  accrue  from  asymmetry  of 
the  lower  extremities,  he  directs  that  the  following  measurements 
should  be  taken:  "1.  Inside  measurements  from  the  superior 
anterior  spines  of  the  ilium  to  the  lower  ends  of  the  internal  malle- 
oli. 2.  Outside  measurements  from  the  superior  anterior  spines  of 
the  ilium  to  the  lower  ends  of  the  external  malleoli.  3.  Measure- 
ments from  the  tops  of  the  great  trochanters  to  the  lower  ends  of 
the  external  malleoli.     4.     Measurements  from    the   bases   of   the 

? ■ ■ 

1  The  Diagnosis  of  Twenty-one  Cases  of  Fracture  of    the  Neck  of  the 
Femur.     Proceedings  of  the  Med.  Soc.  of  the  County  of  Kings,  Oct.  1881. 


DIAGNOSIS.  00 

tibire  to  the  lower  ends  of  the  internal  malleoli.  5.  Measurements 
from  the  superior  anterior  spines  of  the  ilium  to  a  line  drawn  trans- 
versely in  front  between  the  tops  of  the  great  trochanters." 

The  object  of  all  these  comparative  measurements  is  to  deter- 
mine the  possibility  of  original  asymmetry  of  the  two  limbs,  and  to 
find  out,  as  far  as  possible,  if  the  injury  to  the  hip  has  caused  any 
shortening  of  the  limb  on  the  injured  side,  so  that  we  can  infer  the 
probability  of  there  being  a  fracture  of  the  femoral  neck.  He  gives 
the  results  of  examination  of  twenty-one  such  fractures,  where  a 
diagnosis  was  made  without  eliciting  crepitus.  In  eight  of  these 
cases  there  was  probably  impaction.  The  average  shortening  was 
.58  inch,  as  shown  by  the  inside  and  outside  measurements.  In  no 
case  of  fracture  of  the  femoral  neck  does  he  use  force  to  find  crepi- 
tus. He  considers  the  other  evidences  of  fracture  sufficient  for  a 
practical  conclusion.  His  concluding  statements  contain  so  many 
practical  and  useful  suggestions  that  I  do  not  hesitate  to  quote  them 
in  full. 

"  1.  Moving:  the  outer  fragment  when  it  is  in  contact  with  the 
inner  fragment,  will  generally  carry  the  inner  fragment  with  it,  and 
there  will  be  no  crepitus.  And,  when  there  is  impaction,  ordinary 
manipulation  will  not  cause  crepitus  to  be  felt.  Yet  crepitus  may, 
at  times,  be  felt  when  there  is  impaction  of  the  neck  of  the  femur. 
2.  Moving  the  outer  fragment  when  it  is  not  in  contact  with  the 
inner  fragment,  of  course  will  not  give  crepitus.  3.  Hence,  unwar- 
rantable force  will  be  required  in  order  to  get  crepitus  in  many  cases 
of  fracture  of  the  neck  of  the  femur,  and  more  than  this — an 
impacted  fracture  of  the  neck  of  the  femur  may  be  broken  up  by 
severe  manipulation,  and  a  patient  that  would  have  had  a  useful 
limb  may  be  quite  completely  disabled  for  life — for  an  impacted 
fracture  of  the  neck  of  the  femur  is  the  best  setting  of  the  bony 
fragment*  that  a  surgeon  can  have. 

"In  a  suspected  fracture  of  the  neck  of  the  femur,  I  examine 
all  the  witnesses  of  fracture  except  crepitus,  and  if  these  witnesses 
agree  substantially,  I  pronounce  a  verdict  in  favor  of  fracture  of  the 
neck  of  the  femur;  and  if  there  is  a  doubt  as  to  the  correctness  of 
such  a  verdict,  I  give  the  patient  the  benefit  of  that  doubt  by  treat- 
ing the  case  as  if  there  was  a  fracture  of  the  neck  of  the  femur,  and 
then  the  surgeon  receives  a  benefit  from  the  doubt.     But  if  there  is 


56  EXPERIMENTAL   SURGERY. 

no  fracture,  the  patient  has  had  some  days  of  needful  rest,  and  has 
had  a  contused  hip  well  treated." 

The  instrument  recommended  is  an  accurate  steel  tape-line, 
with  feet  and  inches  on  one  side,  and  meters  and  centimeters  on  the 
other  side.  This  tape-line  will  not  elongate  under  tension.  It  is 
superfluous  to  mention  that  the  patient  should  be  placed  in  the 
recumbent  position,  on  an  even  surface,  when  the  measurements  are 
taken.  It  is  to  be  hoped  that  the  text-books  of  the  future  will  say 
less  of  crepitus  as  a  sign  of  fracture,  and  will  substitute  for  it 
accurate  methods  of  measurement. 

Eversion  of  the  limb  is  the  next  most  reliable  symptom.  In 
impacted  fractures  the  position  of  the  limb  depends  on  the  direction 
of  the  fracturing  force.  If  the  force  acts  in  the  direction  of  the 
axis  of  the  cervix,  and  is  severe,  causing  implantation  of  the  whole 
base  of  the  neck  into  the  trochanteric  portion  of  the  femur,  the  limb 
will  retain  its  natural  position.  If  the  anterior  wall  is  impacted  by 
force  applied  against  the  outer  and  posterior  aspect  of  the  trochan- 
ter major,  the  limb  will  remain  in  a  position  of  inward  rotation. 
From  the  anterior  obliquity  of  the  neck,  and  the  usual  manner  of 
falling  (forward  and  on  the  side),  and  from  the  thinness  of  the  com- 
pacta  of  the  posterior  concave  surface  of  the  neck,  as  compared  with 
the  anterior,  we  would  naturally  infer  that  posterior  impaction  takes 
place  in  the  great  majority  of  cases.  This  supposition  has  been 
abundantly  verified  by  clinical  observation.  Impaction,  then,  is 
usually  attended  by  eversion.  If  the  fracture  is  located  within  the 
capsule,  eversion  will  frequently  increase  for  a  few  days,  or  weeks, 
after  the  accident,  from  the  same  causes  which  give  rise  to  secondary 
shortening.  In  cases  of  posterior  impaction,  where  the  fragments 
remain  firmly  implanted  during  the  process  of  repair,  eversion 
increases  from  the  weight  of  the  limb  and  the  inflammatory  absorp- 
tion of  the  impacted  fragments,  permitting  increased  rotation  out- 
ward of  the  lower  fragment. 

The  abnormal  position  of  the  trochanter  major  is  also  an  impor- 
tant diagnostic  sign.  If  we  can  exclude  dislocation  of  the  hip 
upward  and  backward,  the  application  of  Nelaton's  test  may  decide 
the  diagnosis.  In  cases  of  fracture  of  the  neck  of  the  femur,  the 
upper  border  of  the  greater  trochanter  will  be  found  above  Nelaton's 
line,  the  distance  corresponding  with  the  amount  of  shortening.  In 
non-impacted  fractures,  the  false  point  of  motion  diminishes  the  axis 


DIAGNOSIS.  57 

of  rotation  which  the  greater  trochanter  describes  in  rotating  the 
limb.  This  symptom  is  mentioned  simply  to  be  condemned,  as  the 
manipulations  necessary  to  apply  this  test,  like  the  search  for  crepi- 
tiTs.  have  done  a  great  deal  more  harm  than  good. 

In  doubtful  cases,  more  particularly  when  dislocation  is  sus- 
pected, the  patient  should  be  carefully  placed  in  the  erect  position; 
when  the  position  of  the  limb  and  an  examination  of  the  contour  of 
the  hip,  as  well  as  an  inspection  of  all  the  landmarks  in  that  locality, 
will  render  material  assistance  in  arriving  at  correct  conclusions.  In 
case  of  doubt,  if  we  err  at  all,  we  should  err  on  the  safe  side,  and 
treat  the  case  as  one  of  fracture.  Many  cases  which  were  in  a  con- 
dition most  favorable  for  bony  union  to  take  place,  have  been 
rendered  hopeless  by  not  following  this  rule.  The  surgeon  should 
ever  bear  in  mind  that  the  most  favorable  cases  present  the  least 
degree  of  deformity,  and  that  in  our  anxiety  to  make  a  correct  diag- 
nosis we  may  sacrifice  all  the  conditions  which  are  essential  for 
obtaining  bony  union. 

In  response  to  my  circular  as  to  the  possibility  of  bony  union 
after  impacted  intra-capsular  fracture,  Prof.  Alfred  C.  Post,  of 
New  York,  after  replying  in  the  affirmative,  kindly  wrote:  "But  the 
difficulty  in  proving  this  proposition  depends  on  two  circumstances : 
1.  The  want  of  absolute  demonstration  that  fracture  has  actually 
occurred.  2.  The  want  of  opportunity  to  demonstrate  by  autopsy 
that  bony  union  has  actually  occurred. 

"  It  is  a  common  thing  for  a  person  of  advanced  age  to  meet 
with  an  accident  rendering  him  or  her  unable  to  stand  or  walk,  or  to 
raise  the  affected  limb  from  the  bed.  There  is  a  certain  amount  of 
pain  and  lameness  about  the  hip,  with  eversion  of  the  toes,  and  a 
scarcely  perceptible  shortening  of  the  limb.  On  careful  examina- 
tion, without  using  much  force,  neither  crepitus  nor  abnormal 
motion  can  be  detected. 

"  There  is  probable  evidence,  but  not  certain  demonstration  of 
impacted  intra-capsular  fracture.  If  the  surgeon  is  contented  with 
this  imperfect  diagnosis,  he  treats  the  case  as  one  of  fracture,  and 
recovery  takes  place  with  a  perfectly  sound  limb.  But  the  proof  of 
the  fracture  and  reunion  is  incomplete.  If  the  surgeon  in  his 
anxiety  to  obtain  a  perfect  diagnosis  moves  the  limb  freely  in  all 
directions,  he  overcomes  the  impaction,  rupturing  the  cervical  liga- 
ment, demonstrates  beyond  all  doubt  the  existence  of  the  fracture, 


58  EXPERIMENTAL  SURGERY. 

and  effectually  destroys  all  hope  of  reunion.  For  my  part,  I  prefer 
an  imperfect  diagnosis  for  the  surgeon  and  a  perfect  limb  for  the 
patient,  rather  than  a  perfect  diagnosis  for  the  surgeon  and  a  useless 
limb  for  the  patient." 

These  remarks  require  no  explanation.  They  are  concise,  plain, 
practical,  and  to  the  point.  Unimpacted  fractures  of  the  neck  of 
the  femur  seldom  give  rise  to  any  difficulty  in  diagnosis;  the  symp- 
toms attending  them  are  so  well  marked  that  a  correct  conclusion 
can  be  reached  without  causing  needless  suffering,  or  sacrificing 
important  tissues  in  searching  for  any  one  particular  positive  sign. 
Fractures  with  impaction  present  the  same  symptoms  in  a  minor 
degree;  their  presence  can  usually  be  recognized  by  a  careful  con- 
sideration of  symptoms,  the  elucidation  of  which  does  not  necessitate 
the  disengagement  of  the  fragments.  Finally,  if  we  have  reason  to 
believe  that  a  fracture  with  impaction  exists,  it  is  our  duty  to  initiate 
the  treatment  in  accordance  with  such  a  supposition,  although  the 
symptoms  are  not  sufficiently  well  marked  to  warrant  the  diagnosis. 

XIII.    Production  of  Callus. 

In  assuming  an  affirmative  position  concerning  the  possibility 
of  bony  union  after  intra-capsular  fractures,  it  becomes  necessary, 
from  a  theoretical  standpoint,  to  allude  to  the  results  of  recent 
researches  on  the  production  of  callus.  A  brief  historical  review  of 
this  subject  will  be  of  interest  to  illustrate  how  far  the  opinions  of 
surgeons,  regarding  the  mode  of  repair  after  fractures,  have  been 
influenced  by  the  views  they  entertained  as  to  the  source  from  which 
callus  is  produced.  Galen  looked  upon  callus  as  a  substance  thrown 
out  around  the  seat  of  fracture  for  the  purpose  of  cementing  the 
bones  together,  without,  however,  becoming  changed  into  bone. 
Van  Swieten  claimed  that  the  cement  of  Galen  is  transformed  into 
bone.  J.  L.  Petit  compared  the  healing  process  of  bone  with  the 
repair  of  soft  tissues.  Duhamel  de  Monceau  attributed  to  the  peri- 
osteum and  endosteum  the  function  of  producing  callus.  Haller,  and 
his  prosector  Detlef,  believed  that  the  periosteum  takes  no  part  in 
the  regeneration  of  bone,  but  that  callus  is  derived  from  the  frac- 
tured ends  of  the  bones,  more  especially  the  myeloid  tissue. 

Dupuytren,  from  a  clinical  aspect,  revived  the  theory  of  Du- 
hamel, and  at  the  same  time  attributed  to  the  soft  tissues  around 


PRODUCTION   OF   CALLUS.  59 

the  seat  of  fracture,  bone- producing  functions.  He  also  introduced 
the  terms  provisional  and  definitive  callus.  He  made  the  assertion 
that  the  definitive  callus  does  not  make  its  appearance  until  four 
to  five  months  after  the  injury,  and  is  not  complete  before  eight  to 
twelve  months.  Cruveilhier  did  not  recognize  the  classification  of 
callus  described^  by  his  teacher,  and  ascribed  its  source  to  the 
lacerated  soft  parts  surrounding  the  fractured  bone-ends,  the  perios- 
teum, connective  tissue,  muscles,  tendons,  etc. 

Bransby  B.  Cooper  defined  callus  as  a  plastic  exudation  from 
the  inflamed  ends  of  the  broken  bone.  Lambron  asserted  that  a 
broken  bone  can  unite  directly  through  the  medium  of  an  inter- 
fragmentary callus  without  the  formation  of  a  provisional  callus. 
P.  Flourens  believed  that  the  periosteum  alone  is  capable  of  furnish- 
ing material  for  new  bone.  Subsequently,  however,  he  modified  his 
view,  and  made  a  distinction  between  the  periosteal  or  permanent 
callus,  and  the  temporaiy  or  muscular  callus.  August  Voetsch 
speaks  of  callus  as  the  product  of  traumatic  periostitis.  Rokitansky 
declares  that  callus  is  developed  directly  from  bone  and  its  connec- 
tive tissue,  including  the  periosteum. 

Reinh.  Hein,1  who  has  studied  this  subject  with  great  care  by 
means  of  the  microscope  and  experimentally,  has  come  to  the  follow- 
ing conclusions:  The  regeneration  of  broken  and  resected  bones 
commences,  as  a  rule,  from  connective  tissue.  The  process  of 
regeneration  is,  at  times,  limited  solely  to  the  connective  tissue 
of  bone  and  periosteum,  but  in  most  cases  the  connective  tissue  of 
adjacent  parts,  more  especially  the  muscles,  contribute  to  it.  Accord- 
ing to  Virchow,  callus  is  produced  from  connective  tissue  outside  of 
the  bone,  as  well  as  from  myeloid  tissue  in  the  interior  of  bone. 

Preparatory  to  his  studies  on  the  production  of  callus,  Hofmokl 2 
has  traced  the  histology  of  bone  during  foetal  life.  During  the 
development  of  bone,  cartilage  cells  are  transformed  into  bone-cells. 
The  primary  marrow  spaces  are  formed  in  the  interior  of  cartilage- 
cells,  which,  with  their  contents,  are  transformed  into  marrow  spaces. 
The  normal  development  of  callus  appears,  histologically,  as  a  return 
of  perfect  bone  into  its  primary  stage,  embryonal  development.  The 
periosteum,  bone,  and  marrow  are  active  in  the  production  of  callus. 

1  Ueber  die  Regen.  gebrochener  u.  resec.  Knochen.     Virchow's  Archiv  f. 
Path.  Anat.      B.  16,  1858. 

!  i  ber  Caltasbildung.     Virchow  u.  Hirsch,  Jahresbericht,  1874,  p.  294. 


60  EXPERIMENTAL  SURGERY. 

The  neighboring  soft  tissues  assist  in  the  process  of  repair  only  in 
so  far  that  they  may  become  converted  into  bone.  In  point  of  impor- 
tance, the  callus -yielding  tissues  are  arranged  in  the  following 
order:  periosteum,  marrow,  bone.  The  bone-cells  take  an  essential 
part  in  the  production  of  callus,  since  they  become  enlarged,  multiply, 
and  thus  form  marrow  spaces  with  myeloid  cells ;  changes  which  are 
observed  very  distinctly  upon  the  surfaces  of  the  ends  of  broken 
bone,  on  the  periosteal,  as  well  as  on  the  medullary  side.  Ossifica- 
tion invariably  begins  from  the  margins  of  a  medullary  space. 

Gegenbauer1  takes  the  ground  that  bone  is  produced  directly 
from  connective  tissue.  Sharpey's  fibres,  if  traced  carefully,  always 
spring  from  a  bony  point  between  the  Haversian  canals,  from  which 
point  they  radiate  towards  both  sides  into'  the  lamellar  systems. 
The  fibres  form  networks;  and,  at  points  of  intersection,  bone-cells 
are  produced,  and  a  deposit  of  lamellse  takes  place  around  connective- 
tissue  fibres.  The  intercellular  substance  is  regarded  by  Gegenbauer 
as  a  product  of  secretion  of  cell  elements,  and  not  as  a  metamorphosis 
of  cells,  as  was  asserted  by  Waldeyer,  who  believed  that  the  proto- 
plasm of  the  cells  is  transformed  in  part  or  entire  into  basis 
substance. 

Kassowitz,2  in  carefully  studying  the  process  of  ossification,  has 
come  to  the  conclusion,  that  the  deposit  of  earthy  material  in  the 
fibrillary  reticulum,  as  well  as  in  the  osteo-blasts,  is  dependent  on  the 
condition  of  the  circulation.  The  fact  that  the  immediate  neighbor- 
hood of  the  vessels  does  not  ossify,  and  that  the  deposition  of  earthy 
material  takes  place  in  advance  of  the  vessels,  induced  him  to  accept 
the  theory  that  active  circulation  prevents  the  deposition  of  earthy 
material,  while  diminution  of  blood  pressure  favors  ossification. 

Rigal  and  Vignal's3  experimental  researches  on  the  formation 
of  callus  have  an  important  and  direct  bearing  on  the  process  of 
repair  after  fractures.  Their  practical  deductions  may  be  summar- 
ized as  follows:  If  periosteum  is  exposed  to  a  moderate  degree  of 
irritation,  new  bone  is  produced  from  the  marrow  beneath  the  point 
of  irritation  directly,  without  passing  through  ihe  stage  of  cartilage. 
If  irritation  is  increased  by  displacing  the  fragments  and  rubbing 

1  Ueber  die  Bildung  des  Knochengewebes.  2  Mitth.  Jenaische  Zeitschr.  f. 
Med.     B.  3,  S.  206. 

2  Die  Normale  Ossification,  etc.     Wiener  Med.  Jahrb.,  1879,  S.  145. 

3  Virchow  u.  Hirsch's  Jahresbericht,  vol.  i.,  1883,  p.  263. 


PRODUCTION   OF  CALLUS.  61 

the  soft  parts,  the  result  is  cartilage  beneath  the  periosteum,  which 
is  subsequently  converted  into  bone.  If  the  periosteum  is  com- 
pletely destroyed  by  scraping  the  bone,  the  defect  is  repaired  by  a 
connective-tissue  cicatrix,  which  somewhat  resembles  periosteum.  If 
a  circular  piece  of  periosteum  has  been  thus  removed,  and  the  bone 
is  broken  after  cicatrization  has  been  completed,  perfect  union  is  the 
result.  If  the  cortical  layer  of  bone  is  scraped  away  down  to 
the  medullary  canal,  the  defect  is  replaced  by  myeloid  callus.  If  the 
medullary  canal  is  not  opened,  the  process  of  regeneration  is  slower, 
as  a  considerable  period  of  time  will  elapse  until  the  resulting  rare- 
fying osteitis  opens  the  Haversian  canals  sufficiently  to  furnish  the 
required  amount  of  cellular  elements  from  the  medullary  tissue  for 
the  reparative  process. 

Mr.  MacNamara,  in  alluding  to  this  subject,  in  his  excellent 
work,1  as  applied  to  the  neck  of  the  femur  within  the  capsule,  says: 
"  The  ossification  of  the  soft  structures  which  grow  from  the  medul- 
lary spaces  of  the  broken  bone  is,  in  the  human  subject,  a  protracted 
process,  and  the  tissues  concerned  are  so  delicate,  that  unless  they 
are  protected  from  injury  by  means  of  artificial  splints,  they  seldom 
unite  at  all." 

It  is  now  generally  conceded  that  the  provisional  or  temporary 
callus  is  the  product  of  the  periosteal  and  para-periosteal  tissues, 
while  the  definite  or  permanent  callus  is  produced  directly  from  the 
osteoid  and  myeloid  tissues.  The  provisional  callus  is  nature's 
splint,  its  only  object  being  to  immobilize  the  parts  until  the  defini- 
tive callus  firmly  and  permanently  unites  the  fragments.  The  tem- 
porary callus  is  accidental,  and  appears  earliest  and  most  copiously 
where  para-periosteal  tissues  are  most  abundant,  and  motion  between 
the  fragments  greatest;  the  intermediate  or  permanent  callus  is 
produced  later,  and  is  most  certain  to  take  place  in  spongy  bones. 

Fractures  of  the  neck  of  the  femur,  partly  within  and  partly 
without  the  capsule,  unite  with  as  much  certainty  as  fractures  in 
other  localities  in  the  usual  way,  by  the  formation  of  external  and 
intermediate  callus.  In  this  variety  of  fractures  an  abundance  of 
callus,  sometimes  bordering  on  deformity,  designates  the  exact  loca- 
tion of  fracture.  In  intra -capsular  fractures,  as  in  fractures  within 
any  other  joints,  the  conditions  for  the  formation  of  external  callus 

1  Diseases  of  Bones  and  Joints,  1881. 


62  EXPERIMENTAL   SURGERY. 

are  unfavorable;  hence^  we  find  in  all  cases  purporting  to  be  bony 
union,  imperfect  attempts,  if  any,  in  this  direction.  Anatomy, 
physiology,  .and  experimental  research,  all  tend  to  prove  that  in 
cases  of  intra-capsular  fracture  we  have  all  the  conditions  present 
which  are  necessary  for  the  production  of  intermediate  callus,  pro- 
vided the  fragments  are  kept  in  immediate  contact  for  a  sufficient 
length  of  time.  The  neck  of  the  femur  has  been  rendered  vascular 
and  porous  by  senile  degeneration,  and  is  supplied  with  an  abun- 
dance of  bone-producing  myeloid  tissue. 

The  vessels  in  the  red  marrow,  according  to  recent  observation, 
are  also  admirably  adapted  for  the  purpose  of  establishing  early  and 
free  collateral  circulation.  In  1869,  Hoyer  made  the  discovery  that 
the  small  veins  in  the  red  marrow  are  without  walls,  their  lumen 
being  bounded  by  the  parenchyma  of  the  marrow.  Most  of  the 
capillaries  are  also  without  walls.  The  small  arteries  of  the  marrow 
consist  of  a  delicate  tube  of  endothelium,  and  a  single  layer  of  mus- 
cular fibres,  Rindfleisch  corroborated  these  observations.  From 
this  peculiar  structure  of  the  vessels  in  the  marrow,  it  is  easy  to 
understand  how  readily  the  interrupted  circulation  could  be  re- 
established through  immediate  contact  of  the  severed  vessels,  or  by 
canalization  through  the  medium  of  a  blood-clot  or  mass  of  exuda- 
tion material.  That  intermediate  callus  is  thrown  out  in  cases  of 
intra-capsular  fractures,  where  the  fragments  have  not  been  kept  in 
apposition,  and  bony  union  has  failed  to  take  place,  is  evident  from 
examinations  made  of  specimens  where  the  broken  surface  of  the 
upper  fragment,  and  sometimes  the  connecting  ligamentous  band, 
presented  well-marked  spurs  of  hard  compact  bone;  an  appearance 
alluded  to  by  many  observers,  but  more  particularly  by  Sir  Astley 
Cooper  and  Mr.  MacNamara. 

XIV.  ('an  Loose  Detached  Pieces  of  Bone  Produce  Callus,, 
and  Aid  in  Effecting  Bony  Union? 

It  has  been  urged  against  the  possibility  of  bony  union  after 
intra-capsular  fractures  that  the  upper  fragment  is  not  furnished 
with  a  sufficient  vascular  supply  to  maintain  nutrition,  much  less  to 
produce  callus.  Clinical  and  post-mortem  evidence,  however,  tend 
to  prove  that  in  the  great  majority  of  cases  the  fragment  retains  its 
vitality,  and  that  in  many  instances  where  bony  union  has  failed  to 


PRODUCTION   OF  CALLUS.  63 

take  place,  the  fractured  surface  shows  evidence  of  callus  production. 
In  such  cases  where  the  fracture  was  complete,  and  the  fibrous 
investment  of  the  neck  was  completely  torn  across,  the  requisite 
vascular  supply  must  have  been  furnished  through  the  round  liga- 
ment. If  the  upper  fragment  was  not  nourished  from  some  source 
it  would  more  frequently  disappear  by  absorption,  or  suffer  necrosis 
and  act  as  a  foreign  body,  than  has  been  actually  observed  at  the 
bedside,  or  in  the  post-mortem  room.  The  establishment  of  collateral 
circidation  through  the  ligamentum  teres,  in  maintaining  the  vitality 
of  the  upper  fragment  after  intra-capsular  fractures,  is,  unquestion- 
ably, of  more  frequent  occurrence  and  of  greater  importance  than 
many  are  ready  to  admit. 

Taking  it  for  granted,  however,  that  the  ligamentum  teres 
furnishes  no  vessels  to  the  upper  fragment,  I  shall,  nevertheless, 
endeavor  to  show  that  in  case  of  impaction,  it  can  retain  its  vitality, 
assist  in  the  formation  of  callus,  and  enter  into  the  production  of 
bony  union.  It  has  been  known  for  a  long  time  that,  in  compound 
fractures,  perfectly  detached  splinters  remain  innocuous,  and  assist 
in  the  production  of  bony  callus  without  giving  rise  to  any  particular 
symptoms  of  irritation,  John  Hunter1  expressed  himself  as  follows 
on  this  subject:  "Adhesion  of  the  detached  splinters  also  takes 
place,  not  only  in  those  which  are  attached  to  the  soft  parts,  but 
even  such  as  are  entirely  loose.  (This  was  shown  in  a  thigh-bone 
in  which  one  of  the  splinters  had  moved  quite  around  on  its  axis,  and 
adhered  by  its  outer  surface  to  the  bone.)  I  never  examined  a  com- 
pound fracture  without  finding  some  of  those  loose  pieces,  which 
shows  they  must  be  common.  Their  union  must  be  similar  to  that 
in  the  transplanted  teeth." 

Oilier  and  Philip  Walther  inform  us  that  they  have  seen  the 
disc  of  bone  separated  by  the  crown  of  the  trephine  and  entirely 
removed,  reunite  with  the  surrounding  bone  when  replaced. 

Prince,2  in  speaking  of  the  drilling  operation  for  ununited 
fractures,  says:  "When  the  operation  results  in  the  effusion  of 
plastic  lymph  without  suppuration,  there  are  new  centres  of  ossifica- 
tion in  the  chips  of  bone  cut  off  by  the  drill.  These  are  left  in  the 
track  of  the  drill;  some  of  them  in  the  soft  callus  between  the  ends 

1  Works  of  John  Hunter.     Edited  by  James  T.  Palmer,  vol.  i.,  p.  502. 

2  Plastics  and  Orthopedics,  1871. 


64  EXPERIMENTAL   SURGERY. 

of  the  fragments.  That  these  minute  fragments  of  bone  become 
parts  of  the  living  tissue  is  certain;  for,  if  they  did  not,  they  would, 
by  the  offensive  emanations  of  dead  bone,  excite  suppuration  and 
work  their  way  to  the  exterior.  The  importance  of  these  little 
fragments  cut  off  by  the  drill,  as  centres  of  ossification,  may  have 
received  too  little  attention." 

Cases  where  fragments  of  bone  from  the  internal  table  of  the 
skull  were  completely  isolated  and  yet  became  attached  to  the  sur- 
rounding bone  by  permanent  callus,  are  reported  by  Samuel  Thomas, 
Soemmering,  Bernhard  Beck,  Von  Bergmann,  H.  Demme,  Cluston, 
Richet,  and  Ziegler. 

Lossen1  has  studied  this  subject  in  connection  with  comminuted 
fractures  of  the  long  bones,  and  has  come  to  the  conclusion  that  not 
all  loose  fragments  necrose,  but  that  many  are  incorporated  in  the 
callus  and  form  part  of  the  living  ridge  between  the  fractured  ends. 
He  is  of  the  opinion  that  the  vessels  of  the  fragment  unite  at  some 
point  with  other  vessels  in  the  lacerated  district,  thus  establishing 
the  circulation.  In  one  of  his  illustrations  may  be  seen  a  fragment, 
five  centimeters  long  and  one  centimeter  broad,  completely  isolated 
and  denuded  of  its  periosteum,  which,  with  its  wedge-shaped  end, 
had  been  driven  into  the  medullary  cavity.  The  upper  end  was 
perfectly  united  with  the  bony  mass  filling  the  medullary  cavity, 
and  the  lower  end  could  be  seen  beside  the  necrotic  portion  of  the 
fractured  bone.  It  can  safely  be  assumed  in  this  instance,  that 
the  vessels  in  the  medullary  cavity  vascularized  the  fragment  and 
preserved  its  vitality.  Klebs  gives  a  description  of  a  similar  speci- 
men, and  believes  that  the  vitality  of  the  medullary  tissue  and 
periosteum  is  sufficient  to  sustain  the  physiological  activity  of  isolated 
fragments  of  bone  under  favorable  circumstances,  production  of 
new  bone  taking  place  from  the  transplanted  piece  of  bone. 

Von  Bergmann  describes  a  specimen  of  comminuted  fracture  of 
the  femur,  the  result  of  a  gunshot  wound  during  the  Turko- 
Russian  War,  where  a  fragment,  7.2  cm.  long,  15  mm.  broad,  and 
6  mm.  thick,  had  become  completely  detached  from  the  soft  tissues, 
and  had  been  forced  into  the  medullary  cavity,  where  it  became 

1  Kriegs-chirurg.    Erfahrungen  aus  den  Barackenlazarethen  zu  Mannheim, 
Heidelberg  u.  Karlsruhe,  1870,  1871.    Deutsche  Zeits.  f.  Chir.    Band  II.  S.  25. 


PRODUCTION   OF   CALLUS.  65 

firmly  united  with  the  fractured  ends  of  the  bone  and  the  interven- 
ing bony  callus. 

Meek'ren  made  a  series  of  experiments  on  animals  for  the 
purpose  of  establishing  the  fact  that  isolated  fragments  of  bone 
devoid  of  periosteum  wovdd,  under  certain  favorable  conditions, 
retain  their  vitality,  and  were  capable  of  forming  an  attachment  to 
bone  through  the  intervention  of  a  bony  callus.  He  removed  by  the 
trephine  a  disc  of  bone  from  the  skull  of  a  dog,  and  replaced  it. 
On  the  twenty-second  day  he  found  this  disc  firmly  united  by  bony 
callus  to  the  surrounding  bone. 

Flourens  transplanted  a  piece  of  rib  from  a  dog,  under  the 
periosteum  of  the  tibia  of  the  same  animal,  and  in  due  time  found 
it  united  by  bony  callus.  The  well-known  experiments  of  Oilier  are 
familiar  to  every  surgeon,  but  as  he  placed  great  importance  on  the 
preservation  of  the  periosteum  as  an  essential  condition  for  success 
in  bone  transplantation,  they  are  not  of  great  importance  for  our 
purpose.  The  experiments  of  Kosmowski,  to  ascertain  the  exact 
mode  of  repair  in  cases  of  fracture  of  the  skull,  indicate  that  the 
reparative  process  in  general,  and  the  union  of  loose  splinters  of 
bone  in  particular,  are  accomplished  by  the  osteo-genetic  functions 
of  the  medullary  tissue. 

Of  great  practical  importance  are  the  experiments  of  Jakim- 
owitsch.1  The  experiments  were  made  exclusively  on  the  long  bones 
of  dogs,  and  the  vascular  connections  of  the  transplanted  or 
replanted  piece  of  bone  were  demonstrated  by  means  of  gelatine 
injections  stained  with  Berlin  blue.  To  insure  success,  he  places 
great  importance  on  securing  accurate  apposition  and  perfect 
immobilization  of  the  fragment  by  stitching  the  periosteum  or  soft 
parts  over  it,  and  applying  elastic  pressure  and  a  fixation  splint  of 
plaster- of -paris.  The  operation  was  always  done  under  strict 
antiseptic  precautions.  To  prove  that  the  detached  bone  had  become 
a  part  and  parcel  of  the  living  bone,  some  of  the  animals  were  fed 
on  madder,  after  the  example  of  J.  Wolff.  This  staining  material 
is  deposited  during  life  in  the  new  bone  around  the  fragment  in 
greatest  abundance,  while  it  also  follows  the  new  vessels  into  the 
transplanted   piece.     In  almost  all  of   the  cases   after  death,   the 

1  Versuche  fiber  d.  VViederanheilen  vollkommen  getrennter  Knochensplitter, 
Deutsche  Zeitschr.  f.  Chir.     B.  XV. 

5 


66  EXPERIMENTAL   SURGERY. 

vessels  of  the  limb  operated  upon  were  injected  with  gelatine  stained 
with  Berlin  blue,  which  afforded  an  excellent  opportunity  to  follow 
the  course  of  the  vessels  into  the  transplanted  or  replanted  piece  of 
bone.  In  other  instances  the  examination  was  made  even  more 
complete  by  decalcifying  the  bone  and  submitting  it  to  a  microscop- 
ical examination. 

The  results  of  his  experiments  induced  him  to  conclude  that 
replantation  and  transplantation  of  isolated  fragments  of  bone  can 
be  successfully  performed  if  the  detached  piece  retains  its  former 
relations  to  its  immediate  vicinity.  Under  such  circumstances  the 
piece  of  bone  becomes  a  living  part  of  the  bone  through  the  medium 
of  the  intermediate  callus,  and  the  re- establishment  of  vascular 
connections  with  the  surrounding  vessels. 

Gurlt1  describes  and  furnishes  illustrations  of  two  specimens 
of  fracture  of  the  femur,  where  in  each  case  a  large  fragment  of  the 
cortical  layer  near  the  centre  of  the  shaft  had  become  completely 
detached,  and  in  one  instance  turned  completely  around,  and  yet 
they  were  found  firmly  attached  by  bony  union.  Both  specimens 
are  from  the  Museum  of  the  Royal  College  of  Surgeons  of  England, 
being  numbered  108  and  454.  He  states  further,  that  in  comminuted 
fractures,  where  many  loose  fragments  must  exist,  they  furnish  no 
obstacle  to  ready  bony  union.  The  fragments  either  take  part  in  the 
formation  of  callus,  or  are  imbedded  in  the  mass,  and  are  eventually 
removed  by  a  slow  process  of  absorption. 

MacEwen J  resorted  to  transplantation  of  small  pieces  of  bone 
to  restore  extensive  pathological  defects,  believing  that  the  blood-clot 
between  the  fragments  served  as  a  medium  through  which  the  vas- 
cular connection  between  the  detached  bone  and  surrounding  tissues 
was  established.  He  operated  successfully  upon  a  case  of  necrosis  of 
the  humerus,  with  extensive  loss  of  bone  substance,  by  transplanting 
into  a  groove  made  in  the  bone,  numerous  wedge-shaped  pieces  of 
bone  derived  from  the  tibise  of  six  rickety  children,  the  fragments 
being  supplied  with  periosteum  and  marrow  tissue.  The  bone  grafts 
retained  their  vitality,  united  with,  and  grew  with  the  bone. 

Prof,  von  Nussbaum  has  introduced  transplantation  of  bone  as 
a  legitimate  operation  in  surgery,  for  the  purpose  of  supplying  bone 

1  Op.  cit. 

2  Virchow  u.  Hirsch,  Jahresbericht,  vol.  ii.,  1881,  p.  332. 


PRODUCTION   OF   CALLUS.  67 

defect  in  cases  of  ununited  fracture;  and  his  success,  as  well  as  simi- 
lar operations  by  several  other  German  surgeons,  certainly  prove 
that  the  vitality  of  even  compact  bone  is  sustained  by  a  minimum 
amount  of  blood-supply  through  a  narrow  strip  of  periosteum. 

Spongy  bone,  containing  an  abundance  of  marrow  tissue  and  a 
rich  supply  of  blood-vessels,  is  endowed  with  a  higher  degree  of 
vitality  than  compact  bone;  and  is,  consequently,  better  adapted  to 
enter  into  union  with  surrounding  tissues,  in  case  it  has  become 
detached. 

It  has  also  been  established  by  way  of  experiment,  that  in  ani- 
mals, marrow  can  be  transferred  to  different  parts  of  the  body,  and 
that  if  the  operation  is  successful,  the  transplanted  marrow  will  pro- 
duce bone.  Baikow,  Groujon,  and  Oilier  were  successful  in  their 
auto-transplantations  of  marrow,  but  failed  when  the  tissue  was 
transferred  from  one  animal  to  another.  The  most  extensive  and 
reliable  experiments  on  marrow  transplantation  have  been  made  by 
P.  Bruns.1  He  operated  upon  sixty  chickens  and  six  dogs.  He 
failed  repeatedly  as  long  as  he  transplanted  the  marrow  from  animal 
to  animal,  but  as  soon  as  he  limited  his  experiments  to  auto-trans- 
plantation, he  succeeded  in  the  great  majority  of  cases.  Of  nineteen 
auto-transplantations,  twelve  proved  successful,  three  failed  on 
account  of  suppurative  inflammation  following  the  operation,  and 
in  four  the  transplanted  tissue  was  absorbed. 

The  operation  consisted  in  removing  cylindrical  pieces  of  mar- 
row from  the  femur  or  tibia,  2  to  8  cms.  in  length,  and  transplanting 
them  under  the  skin  of  the  same  animal.  After  the  fourteenth  day 
foci  of  ossification  could  be  distinctly  seen,  which  enlarged  and 
became  confluent  from  the  twentieth  to  the  twenty-fourth  day. 
Ossification  was  preceded  by  an  active  proliferation  of  spindle-shaped 
cells.  The  formation  of  bone  takes  place  from  the  pre  existing 
osteo-blasts  in  marrow,  an  opinion  which  is  also  supported  by 
Waldeyer.  The  yellow  and  red  marrow  were  used  in  these  experi- 
ments, and  proved  alike  capable  of  producing  bone. 

The  success  attending  bone  and  marrow  transplantation  con- 
stitutes a  potent  argument  in  favor  not  only  of  the  possibility  but 
the  probability  of  bony  union  after  intra-capsular  fractures,  in  the 

1  Ueber  Transplantation  von  Knochenmark,  Archiv.  fur  Klinische  Chirur- 
gie.     B.  XXVI.  S.  601. 


68  EXPERIMENTAL  SURGERY. 

event  that  the  fractured  ends  are  in  accurate  and  undisturbed  appo- 
sition for  the  requisite  length  of  time.  The  neck  of  the  femur  in  a 
state  of  senile  atrophy  furnishes  a  number  of  favorable  conditions 
for  a  speedy  production  of  bony  callus.  It  is  very  vascular,  the 
compact  tissue  attenuated,  the  spongiosa  exceedingly  porous,  and  its 
meshes  distended  with  an  abundance  of  bone-producing  myeloid 
tissue. 

If  perfectly  detached  and  denuded  pieces  of  compact  bone,  and 
isolated  masses  of  marrow,  can  be  transferred  to  a  distant  part  of  the 
body,  and  when  properly  transplanted,  not  only  retain  their  vitality, 
but  become  vascular  and  produce  bone,  I  can  see  no  reason  why  the 
upper  fragment  in  intra-capsular  fractures,  which  is  still  retained  in 
its  natural  location,  should  not  manifest  the  same  power  of  self- 
preservation  and  repair.  In  impacted  fractures  the  bone -tissue, 
marrow,  and  lacerated  vessels  are  brought  in  such  immediate  contact, 
that  the  reparative  process  is  taxed  only  to  its  minimum  extent  in 
restoring  the  continuity  of  the  bone.  In  these  instances  we  have  an 
example  of  bone  and  marrow  transplantation  under  the  most  favor- 
able conditions,  and  the  reason  it  does  not  succeed  oftener,  is  simply 
because  these  favorable  conditions,  as  a  rule,  do  not  exist,  or  are  not 
allowed  to  exist,  for  a  sufficient  length  of  time. 

XV.    Specimens  of  Bony  Union  after  Intra-Capsular 

Fracture. 

It  is  not  my  purpose  to  enter  into  a  discussion  of  the  many 
specimens  in  which  bony  union  has  been  claimed  by  their  possessors. 
Many  of  them  have  been  the  object  of  the  most  rigid  criticism,  at 
different  times  and  at  the  hands  of  different  writers.  While  careful 
and  competent  men  have  brought  these  specimens  before  the  profes- 
sion as  typical  examples  of  union  by  bone  within  the  capsule,  equally 
good  observers  have  failed  to  see  the  evidence  which  justified  these 
claims.  I  have  tabulated  only  the  cases  reported  by  competent 
observers,  and  where  the  diagnosis  was  verified  by  a  post-mortem 
examination. 


SPECIMENS   OF  BONY   UNION  AFTER   FRACTURE. 


69 


No. 

Name  of 
Reporter. 

Where  Mentioned  or  Classified. 

In  Whose  Possession. 

1 

Adams,  R., 

Todd's  Cyclopedia,  vol.  ii.  p.  813. 

Adams. 

2 

Adler, 

Am.  Journ.  Med.  Sci.,  April,  1873. 

Adler. 

3 

Bardeleben, 

Lehrbuch  d.  Chir.     B.  ii.  p.  477. 

Goyrand. 

4 

Brulatour, 

Med.-Chir.  Transactions,  vol.  xiii. 

Brulatour. 

5 

Bryant, 

Bryant's  Surgery,  p.  843. 

Museum  Guy's  Hospital. 

6 

Callender, 

St.  Barthol.  Hosp.  Rep.,  vol.  i.  p.  154. 

7 

Chassaignac, 

These  inaugurate. 

Van  Houte. 

8 

Chelius, 

Handb.  d.  Chir.    B.  i.  p.  319. 

Chelius. 

9 

Chelius, 

Handb.  d.  Chir.     B.  i.  p.  319. 

Soemmering's  collection. 

10 

Cushing, 

Bigelow,  The  Hip,  p.  133. 

11 

Earle. 

Practical  Obser.  in  Surgery,  1823,  p.  97. 

12 

Fawcington, 

Am.  Journ.  Med.  Sci.,  vol.  xv.  p.  531. 

Fawcington. 

13 

Fischer,  H., 

Personal  communication. 

Pathological  Museum,  Breslau. 

14 

Fischer,  H., 

Personal  communication. 

Ponfick. 

15 

Field, 

Amesbury  on  Fractures. 

Field. 

16 

Geddings, 

Am.  Journ.  Med.  Sci.,  Jan.  1847. 

Geddings. 

17 

Gurlt, 

Knoehen-brueche,  vol.  i.  p.  308. 

Giessen  Museum. 

18 

Hamilton, 

Hamilton  on  Fractures,  p.  407. 

Hamilton. 

19 

Harris, 

Am.  Journ.  Med.  Sci.,  vol.  xviii.  p.  246. 

Harris. 

20 

Holthouse, 

Holmes'  System  of  Surgery,  vol.  ii. 

St.  George's  Hosp.,  Spec.  No.  112 

21 

Howship, 

Med.-Chir.  Transitions,  vol.  xiv. 

Howship. 

22 

Hutchinson, 

Illustr.  Clin.  Surgery,  vol.  ii.  p.  8. 

Leeds  Hospital  Museum. 

23 

Hutchinson, 

"Museum  Notes"  of  Jan.  23,  1870. 

Museum  of  Trinity  Coll., Dublin. 

24 

Jones, 

Med.-Chir.  Transactions,  vol.  xxiv. 

Jones. 

25 

Kocher, 

Personal  communication. 

Pathological  Museum,  Berne. 

26 

Kroenlein, 

Personal  communication. 

Pathological  Museum,  Zurich. 

27 

Langstaff, 

Med.-Chir.  Transactions,  vol.  xiii. 

Langstaff. 

28 

Maas. 

Personal  communication. 

Pathological  Museum,  Freiburg 

29 

Malgaigne, 

A  Treatise  on  Fractures,  1859,  p.  555. 

Musee  Dupuytren. 

30 

March, 

Trans.  Am.  Med.  Association,  1858. 

Museum  Albany  College. 

31 

March, 

Trans.  Am.  Med.  Association,  1858. 

Museum  Albany  College. 

32 

March, 

Trans.  Am.  Med.  Association,  1858. 

Museum  Albany  College. 

33 

Mussey, 

Am.  Journ.  Med.  Sci.,  1857,  p.  299. 

Mussey. 

34 

Mussey, 

Am.  Journ.  Med.  Sci.,  1857,  p.  299. 

Mussey. 

35 

Mussey, 

Am.  Journ.  Med.  Sci.,  1857,  p.  299. 

Mussey. 

36 

Pope, 

Hamilton  on  Fractures,  p.  407. 

37 

Post, 

Personal  communication. 

Destroyed  in  fire  of  Univ.  Med. 

Col. 
Wuerzburg  Museum. 

38 

Riedinger, 

Studien  uber  grund  u.  einkeilung  der 

Schenkelhalsbrueche,  1874.     PI.  xi. 

39 

Roberts, 

Personal  communication. 

Museum  Pennsylvania  Hospital. 

40 

Sands, 

New  York  Med.  Record,  June  1,  1869. 

Sands. 

41 

South, 

Chelius  Surgery  by  South,  vol.  i.  p.  621. 

South. 

42 

South, 

Quoted  by  Hamilton,  Ed.  1871,  p.  363. 

Museum  St.  Barthol.  Hosp. 

43 

Smith,  H.  H., 

Princ.  and  Prac.  of  Surg.,  vol.  ii.  p.  610. 

Wister  and  Horner  Museum. 

44 

Smith,  H.  H., 

Princ.  and  Prac.  of  Surg.,  vol.  ii.  p.  610. 

Smith. 

45 

Smith,  R.  W., 

Dublin  Journal  Med.  Sci.,  Jan.  1873. 

Museum  Trinity  College. 

46 

Smith,  R.  W., 

Dublin  Journal  Med.  Sci.,  Jan.  1873. 

Museum  Trinity  College. 

47 

Spalding, 

Bost.  Med.  &  Surg.  Journ.,  Mar.  4, 1858, 

Spalding. 

48 

Stanley, 

Med.-Chir.  Review,  vol.  xii.  p.  170. 

Stanley. 

49 

Swan, 

On  Diseases  of  Nerves,  p.  304. 

Swan. 

50 

Selden, 

Trans.  Virginia  State  Med.  Soc,  1877. 

Selden. 

51 

Selden, 

Trans.  Virginia  State  Med.  Soc,  1877. 

Selden. 

52 

Parker,  W., 

Johnson,  lntracap.  Fract.,  1857,  p.  28. 

W.  Parker. 

53 

Zeiss, 

Hamilton,  Fract.  and  Disl.,  1880,  p.  406. 

Zeiss. 

54 

Zeiss, 

Hamilton,  Fract.  and  Disl.,  1880,  p.  406. 

Zeiss. 

I  will  only  give  a  description  of  a  few  undoubted  specimens, 
for  the  purpose  of  illustrating  the  alterations  which  take  place  in  the 
femoral  neck  during  the  process  of  repair.  Ii.  Adams  (Table,  No.  1): 
•The  round  ligament  was  sound.  The  head  and  neck  of  the  bone 
had  lost  their  normal  obliquity,  and  were  directed  nearly  horizontally 
inwards:  the  cervix  presented,  both  anteriorly  and  posteriorly,  evi- 
dence of  a  transverse  intracapsular   fracture  having  occurred;  the 


70  EXPERIMENTAL  SURGERY. 

globule-shaped  head  was  closely  approximated  behind  and  below  to 
the  posterior  intertrochanteric  line,  and  to  the  lesser  trochanter,  so 
that  the  neck  seemed  altogether  lost,  except  anteriorly,  where  a  very 
well-marked  ridge  of  bone  showed  the  seat  of  the  displacement  and 
of  the  union  of  the  fragments.  This  ridge  is  evidently  the  upper 
extremity  of  the  lower  fragment  of  the  cervix.  The  fracture  of  the 
neck  posteriorly  was  found  to  have  been  closer  to  the  corona  of  the 
head  than  anteriorly,  and  the  fibro-synovial  fold  in  the  former  situa- 
tion remained  unbroken.  A  section  has  been  made  of  the  bone 
through  the  head,  neck  and  trochanter;  one  portion  has  been  sub- 
jected to  maceration  and  boiling;  and  the  bony  union  has  been 
unaffected  by  these  tests.  Scarcely  any  portion  of  the  neck  can  be 
said  to  have  been  left.  The  section  shows  the  compact  line  which 
denotes  the  union  of  the  fragments;  the  head  and  shaft  seem  to  be 
mutually  impacted  into  each  other,  and  almost  the  whole  of  the 
cervix  has  been  absorbed;  the  line  of  union  is  serrated,  solid  and 
immovable;  and  the  cells  of  the  head  and  substance  of  the  shaft 
seem  to  communicate  freely  in  all  places,  except  where  the  thin  line 
of  compact  tissue  here  and  there  points  out  the  seat  of  the  welding 
together  of  the  remaining,  portions  of  the  head  and  neck  of  the 
femur." 

As  Mr.  R.  Adams,  in  his  article,  "Abnormal  Conditions  of  the 
Hip-joint,"  in  Todd's  Cyclopaedia,  took  the  ground  that  bony  union 
was  impossible,  and  commented  unfavorably  on  the  cases  which  had 
been  reported  as  cases  of  bony  consolidation,  it  is  evident  that  this 
case  must  have  presented  convincing  proof  in  order  to  change  his 
views  on  this  subject.  The  value  of  this  specimen  is  increased  by  a 
full  clinical  history  of  the  case. 

Chorley's  specimen,  described  by  Jonathan  Hutchinson  (Table, 
No.  22) :  "  The  bone,  which  supplied  the  illustration  I  now  publish, 
is  one  of  the  many  treasures  of  the  Pathological  Museum  of  the 
Leeds  Hospital.  The  drawings  were  (by  permission)  made  for  me 
by  Mr.  Tuff  en  West,  some  years  ago,  at  the  time  of  the  visit  of  the 
British  Medical  Association  to  Leeds.  The  specimen  is  the  best 
example  of  union  of  an  intra-capsular  fracture  with  which  I  am 
acquainted,  and,  as  it  appears  to  be  beyond  all  cavil,  I  have  great 
pleasure  in  endeavoring  to  secure  for  it  a  wider  recognition.  The 
drawings  show  so  exactly  the  condition  of  the  bone  that  it  is  scarcely 
necessary  to  describe  them.     (Figs.  9,  10,  11.)     It  will  be  seen  that, 


SPECIMENS   OF  BONY    UNION  AFTER   FRACTURE. 


71 


whilst  the  transverse  fracture  is  wholly  within  the  capsule,  and 
nowhere  more  than  half  an  inch  from  the  articular  head,  yet,  that 
on  the  back  of  the  cervix,  some  fragments  have  been  detached,  which 
pass  much  further  out.  It  is  worth  notice,  also,  that  in  the  section 
of  the  bone,  the  edge  of  the  lower  outer  layer  is  seen  to  catch  in  the 


Fig.    9.     Anterior   view  of  Bony  Union  after  Fracture  of    Neck   of    Femur. 

(Hutchinson.) . 

cancellous  tissue  of  the  articular  fragment,  thus  constituting  a  degree 
of  impaction  which,  no  doubt,  much  favored  fixation  and  union. 
The  specimen  was  obtained  by  the  late  Mr.  Chorloy,  formerly  Sur- 
geon to  Leeds  Infirmary,  from  the  body  of  a  gentleman,  aged 
seventy,  whom  he  h <•  i< I  attended  several  years  before  his  death,  with 
the  diagnosis  of  fracture  of  the  neck  of  the  thigh-bone.     The  treat 


72 


EXPERIMENTAL   SURGERY. 


ment  had  been  very  careful  immobilization  and  long-continued  con- 
finement to  bed.  The  recovery  had  been  such  that  the  patient  had 
been  able  to  walk  well  with  a  stick." 

The  well-known  ability  of  Mr.  Hutchinson  is  a  sufficient  guar- 
antee for  the  genuineness  of  this  specimen. 


Fig.  10.     Posterior  View  of  Bony  Union  after  Fracture  of  Neck  of  Femur. 

(Hutchinson.) 

Riedinger's  specimen  (Table,  No.  38) :  "  The  neck  of  the  femur 
is  considerably  shortened,  and  the  head  inclines  so  far  backward, 
that,  superiorly,  it  comes  almost  completely  in  contact  with  the 
posterior  inter-trochanteric  line.  From  behind,  only  the  carti- 
laginous surface  of  the  head  can  be  seen;  downward,  the  neck  is 
visible  to  the  extent  of  1  cm.     Above,  the  length  of  the  neck  is  1.5 


SPECIMENS   OF  BONY   UNION  AFTER   FRACTURE. 


73 


cm.  On  the  anterior  surface,  the  well-marked  denticulated  line  of 
fracture  can  be  seen  close  to  the  head.  Its  length  is  3  cm.  A 
longitudinal  section  of  the  upper  portion  of  the  femur,  into  an 
anterior  and  posterior  half,  discloses  the  line  of  fracture  in  the 
loosely  cancellated  tissue  of  the  spongiosa,  and  more  clearly  shows 


Fig.  11.     Vertical  section  showing  Bony  Union  after  Fracture  of  Neck  of 
Femur.     (Hutchinson.) 

the  impaction  of  the  lower  fragment  into  the  head,  which  is  espe- 
cially well  marked  in  the  lower  cortical  portion  of  the  neck  (Adams' 
arch).  The  length  of  the  Implanted  portion  amounts  to  2  cm." 
(Figs.  12.  13.  L4) 

As  Riedinger  Las  made  Eractures  of  the  neck  of  the  femur  a 
special   study   for  many  years,  no  one  would  for  a  moment   doubt 


74 


EXPERIMENTAL   SURGERY. 


the   correctness   of    bis    description,    or    the    authenticity   of    this 
specimen. 

Gurlt's  specimen  (Table,  No.  17):  "The  fracture  runs  obliquely 
through  the  neck  of  the  femur;  in  front  it  is  three-fourths  of  an 
inch  from  the  base  of  the  neck,  posteriorly  a  little  less.  The  head 
of  the  bone  is  displaced  somewhat  backward  and  downward  and  is 


ws§) 


Fig.  12.     Anterior  view  of  Bony  Union  after  Intra-Capsular  Fracture. 

(Riedinger.) 

united  by  bone,  although  the  line  of  fracture  is  still  visible  in 
places."     (Figs.  15,  16.) 

Gurlt's  name  occupies  a  position  foremost  among  writers  on 
fractures,  present  and  past,  and  his  decision  admits  of  no  appeal. 

To  prove  the  validity  of  any  specimen,  it  is  necessary  to  examine 
for  evidences  which  will  warrant  an  affirmative  answer  to  the  fol- 
lowing questions:     1.  Has  the  bone  been  fractured?     2.  Was  the 


SPECIMENS   OF  BONY    UNION  AFTER   FRACTURE. 


75 


fracture  within  the  capsular  ligament  ?     3.  Has  the  fracture  consoli- 
dated by  bone  ? 

The  first  question  can  only  arise  in  specimens  without  a  clinical 
history.  Post-mortem  specimens  have  been  brought  forward  as 
instances  of  bony  union,  when  the  changes  in  the  bone  were  due  to 
other  causes,  as  rickets  or  senile  coxitis.  In  all  cases  of  interstitial 
absorption  without  fracture,  the  wasting  of  the  neck  takes  place  in  a 


Fig.  13.     Posterior  view  of  Bony  Union  after  Intra-Capsular  Fracture. 

(Riedinger.) 

more  symmetrical  manner;  the  neck  may  become  greatly  shortened, 
and  yielding  to  the  vertical  pressure,  the  head  may  descend  to  a 
level  with  the  upper  border  of  the  trochanter  major,  but  does,  not 
incline  backward,  as  is  generally  the  case  when  fracture  has  taken 
place.  In  senile  coxitis  the  head  is  enlarged,  and  presents  the  char- 
acteristic  deep  depression  for  the  round  ligament;  at  the  same  time 
it-  upper  and  anterior  surface  is  deprived  of  cartilage,  and  presents 
an   eburnated  appearance.     (Fig.    17.)      If  rickets  or  senile  osteo. 


76 


EXPERIMENTAL   SURGERY. 


malacia  has  been  the  cause  of  the  deformity,  the  disease  affects 
both  joints  simultaneously.  An  intra-capsular  fracture  always 
unites  with  some  degree  of  deformity.  Longitudinal  sections  of  the 
specimens  usually  disclose  the  direction  and  extent  of  displacement 
of  the  fragments. 

From  causes  which  have  been  previously  enumerated,  absorption 
of  the  neck  is  more  extensive  in  the  posterior  portion  of  the  neck 
than  in  the  anterior,  permitting  the  head  to  approach  the  posterior 


Fig.  14.     Vertical  section  showing  Impaction  with  Bony  Union  after 
Intra-Capsular  Fracture.     (Riedinger.) 

inter-trochanteric  ridge.  If  the  fracture  has  been  entirely  within 
the  capsule,  little  or  no  provisional  callus  is  found  over  the  seat  of 
fracture,  while  in  senile  coxitis  irregular  bony  masses  are  found  over 
different  portions  of  the  neck.  The  writer  on  fracture  of  the  neck 
of  the  femur  in  Eulenburg's  Encyclopaedia  says:  "If  bony  union 
takes  place,  the  femoral  neck  disappears  almost  completely  by 
absorption,  the  head  coming  nearly  in  contact  with  the  trochanteric 
region.  Little  or  no  callus  is  found  upon  the  surface  of  the  neck." 
Bardeleben1  indicates  the  following  appearances  as  characteristic 

1  Lehrbuch  d.  Chirurgie,  B.  II.  1871,  S.  473. 


SPECIMENS   OF  BONY   UNION  AFTER   FRACTURE. 


77 


of  union  by  bone  after  fracture  within  the  capsule:  "If  it  can  be 
ascertained  with  certainty  that  a  fracture  had  occurred  during  life, 
and  on  post-mortem  examination  we  find  a  bone  cicatrix,  that  is  a 
disc  of  dense  bone  through  the  intra-capsular  portion  of  the  neck, 
and  there  are  no  other  evidences  of  synovitis  or  osteitis,  then  we  are 
justified  in  claiming  for  such  a  case  that  a  fracture  within  the  capsule 
has  united  by  bone." 

Erichsen1  remarks:    "When  bony  union  has  taken  place,  the 
head  will  usually  be  found  somewhat  twisted  around,  in  such  a  way 


Fig.  15. 
Anterior   view  of   Bony  Union  after 
Intra-Capsnlar  Fracture. 
(Gurlt.) 


Fig.  16. 

Section  through  Neck  showing  Bony 

Union  within  Capsule. 

(Gurlt.) 


that  it  looks  toward  the  lesser  trochanter,  owing  to  the  eversion  that 
has  taken  place  in  the  lower  fragment." 

Gurlt "  states  that  absorption  of  the  fragments  takes  place 
exclusively  in  fractures  involving  joints,  and  proceeds  hand  in  hand 
with  the  process  of  repair.  In  some  joints,  as  in  the  hip-joint,  it 
may  be  so  extensive  that  almost  the  entire  neck  is  absorbed.  This 
is  more  likely  to  be  the  case  if  the  fracture  is  within  the  capsule.  In 
such  cases  the  head  of  the  bone  may  be  very  near  the  great  trochan- 


1  The  Science  and  Art  of  Surgery,  1869. 

2Handbuch  d.  Lehre  v.  d.  Knochenbruechen,  vol.  i.,  1862. 


78 


EXPERIMENTAL  SURGERY. 


ter  at  the  base  of  the  cervix  femoris.     The  cause  of  the  absorption 
is  not  known. 

The  characteristic  deformity  presented  by  specimens  of  bony 


Fig.  17.     Appearances  of  Head  and  Neck  of  Femur  in  Senile  Coxitis. 
(Richardson.) 

union  of  fracture  through  the  neck  of  the  femur  corresponds  to  the 
direction  of  the  displacing  forces — shortening  and  eversion.  The 
cause  of  the  primary  displacement  is  the  fracturing  force  itself. 
The   secondary  displacement   takes   place   upon   the    accession   of 


SPECIMENS   OF  BONY   UNION   AFTER   FRACTURE.  79 

inflammatory  osteo-porosis,  and  is  the  result  of  softening  and  absorp- 
tion of  the  bone,  muscular  contraction,  and  gravitation. 

Exacting  critics  have  questioned  the  validity  of  many  specimens 
of  bony  union  on  the  ground  that  the  fracture  was  not  purely  intra- 
capsular. Indeed,  this  argument  has  been  the  main  support  of  all 
modern  believers  in  non-union.  In  all  specimens  of  bony  union,  the 
point  of  attachment  of  the  posterior  portion  of  the  capsular  ligament 
is  changed;  instead  of  being  inserted  near  the  middle  of  the  femoral 
neck,  it  is  found  attached  at  or  near  the  posterior  inter-trochanteric 
line,  and  on  this  account  it  has  been  asserted  that  the  fracture 
extended  beyond  the  capsular  ligament. 

I  believe,  however,  that  this  alteration  in  the  attachment  of  the 
capsule  admits  of  a  more  satisfactory  explanation.  All  fractures  are 
followed  by  inflammatory  osteo-porosis  in  the  ends  of  the  broken 
bones,  and  this  is  especially  well  marked  in  the  articular  extremities 
of  the  long  bones.  During  an  inflammation  of  this  kind,  the 
periosteal  covering  of  the  bone  is  loosened,  and  readily  changes  its 
relative  position  to  the  bone  during  the  process  of  interstitial  absorp- 
tion, and  carries  with  it  the  capsular  ligament  with  which  it  is 
intimately  connected.  Interstitial  absorption  precedes  and  attends 
the  production  of  callus,  and  is  most  active  in  that  portion  of  the 
bone  supplied  with  the  greatest  number  of  blood-vessels.  The 
upper  fragment  being  scantily  supplied  with  blood-vessels,  absorp- 
tion, if  it  takes  place  at  all,  occurs  at  a  later  date,  and  progresses 
very  slowly;  while  the  reverse  is  the  case  in  the  lower  fragment. 
The  point  of  attachment  of  the  capsular  ligament  is  no  indication  as 
to  the  seat  of  fracture,  as  almost  the  entire  femoral  neck  may  dis- 
appear by  absorption,  and  as  the  capsule  approaches  the  trochanteric 
region  in  proportion  to  the  amount  of  bone  absorbed.  A  more 
important  sign  is  the  presence  or  absence  of  new  bone  upon  the 
outside  of  the  capsule.  In  intracapsular  fractures  little  or  no 
external  callus  is  produced  within  or  without  the  capsule;  while 
extracapsular  fractures,  from  obvious  anatomical  reasons,  yield  an 
abundance  of  exuberant  callus,  part  of  which  at  least,  remains 
permanently. 

The  last  test  is  to  ascertain  the  nature  of  the  connecting  medium. 
This  can  be  done  by  submitting  the  specimen  to  a  microscopical 
examination,  or  to  the  boiling  process.  In  the  first  case  the  tissues 
at  the  seat  of  fracture  will  show  the  histological  elements  of  true 


80  EXPERIMENTAL  SURGERY. 

bone  in  all  genuine  specimens.  The  boiling  process  will  destroy 
the  ligamentous  union  between  the  fragments  in  all  doubtful  cases; 
it  is,  therefore,  the  simplest  and  most  certain  method  to  demonstrate 
the  restoration  of  the  continuity  of  the  broken  bone. 

In  recapitulation,  it  may  be  stated,  that  the  validity  of  a  speci- 
men is  established  whenever  the  clinical  history  has  revealed  the 
existence  of  fracture  during  life,  and  the  post-mortem  examination 
has  demonstrated  that  the  fracture  has  been  within  the  capsule,  and 
that  the  union  is  by  bone. 

XTI.    Non-Union  after  Intra-Capsnlar  Fracture. 

Sir  Astley  Cooper  enumerates  the  causes  of  non-union  under 
the  following  heads:  1.  Want  of  proper  apposition  of  the  bones. 
2.  Want  of  pressure  of  one  extremity  of  the  broken  neck  upon  the 
other,  even  though  the  limb  preserves  its  length,  and  the  fractured 
parts  are  consequently  not  much  displaced.  3.  Absence  of  nutrition 
in  the  head  of  the  thigh-bone.     4.  Atrophy  of  bone. 

The  first  cause  can  apply  only  to  non-impacted  fractures,  where 
treatment  has  failed  to  keep  the  fractured  ends  in  immediate  and 
uninterrupted  contact  for  a  sufficient  length  of  time  for  union  by 
bone  to  take  place.  This  constitutes  the  principal,  if  not  the  only 
cause  of  non-union.  There  is  no  other  fracture  where  immobiliza- 
tion is  so  difficult  to  accomplish.  Every  movement  of  the  body 
disturbs  the  fractured  ends.  No  apparatus  yet  devised  has  answered 
the  first  and  principal  indication  in  the  treatment  of  all  fractures, 
namely,  to  secure  immobility  and  permanent  coaptation. 

Colles,1  who  fully  endorses  the  views  of  Sir  Astley  Cooper  on 
the  subject  of  fractures  within  the  capsule,  in  speaking  of  the  causes 
of  non-union,  remarks:  "However  this  may  be,  I  think  the  difficulty 
of  keeping  the  parts  motionless  on  each  other  would  be  sufficient  of 
itself  to  account  for  it."  Gurlt,2  who  has  studied  the  process  of 
repair  in  fractures  with  the  most  assiduous  care,  says:  "There  is  no 
specific  tendency  to  non-union  in  any  form  of  fracture.  If  the  ends 
of  the  broken  bones  can  be  kept  in  accurate  apposition,  union  by 
bone  will  take  place."     As  illustrations  of  this  statement,  he  men- 

1  Lectures  on  Surgery,  1845. 

2  Handbuch  der  Lehre  von  der  Knochenbruechen,  vol.  i,  1862. 


NON-UNION  AFTER   INTRA-CAPSULAR   FRACTURE.  81 

tions  the  following  fractures:  Neck  of  femur,  patella,  coronoid 
process  of  inferior  maxilla,  coracoid  process  of  scapula,  olecranon, 
coronoid  process  of  ulna,  trochanter  major,  tuberosity  of  calcaneum, 
spinous  processes  of  vertebrae,  and  some  of  the  sharp  prominences 
of  the  pelvic  bones. 

The  second  cause  of  non-union,  want  of  pressure  of  one  frag- 
ment upon  the  other,  implies  a  want  of  apposition,  expressed  in 
other  words.  Dupuytren  and  Brainard  were  of  the  opinion  that 
oblique  fractures  resulted  more  frequently  in  non-union  than  trans- 
verse fractures,  and  Dupuytren  applied  this  rule  to  fractures  of  the 
neck  of  the  femur.  Experience  has  shown  that  of  all  fractures 
within  the  capsule,  none  are  so  prone  to  result  in  non-union  as 
transverse  fractures  through  the  narrowest  portion  of  the  neck. 
Lateral  pressure  applied  over  the  trochanter  major  is  an  important 
measure  for  obtaining  union  by  bone,  but  this  desirable  result  does 
not  follow  from  the  fact  that  pressure  is  made,  but  simply  because, 
by  the  pressure,  coaptation  and  immobilization  are  effected. 

Deficient  vascular  supply  of  the  upper  fragment  is  prominently 
mentioned  by  almost  every  author  against  the  probability  of  union 
by  bone.  On  the  other  hand,  it  is  generally  submitted  that  fractures 
of  the  anatomical  neck  of  the  humerus  unite  by  bone,  and  that  com- 
pletely isolated  pieces  of  bone,  when  properly  replanted  or  trans- 
planted, retain  their  vitality  and  physiological  properties.  It  is  also 
well  known  that  traumatic  or  pathological  epiphyseolysis  may  be 
repaired  by  bony  callus.  Why  should  the  upper  fragment  in  intra- 
capsular fractures,  with  at  least  a  doubtful  supply  of  blood  through 
the  round  ligament,  make  an  exception  to  this  general  rule  ?  Simply 
because,  in  this  instance,  coaptation,  without  impaction,  is  next  to 
impossible,  with  the  present  method  of  treatment. 

On  this  point  MacNamara1  makes  this  statement:  "I  hardly 
think  the  non-union  between  the  ends  of  the  bone  in  instances  of 
intra-capsular  fracture  of  the  neck  of  the  femur  is  most  frequently 
due  to  the  insufficient  blood-supply  of  the  head  of  the  bone;  other- 
wise we  should  more  commonly  meet  with  examples,  after  fractures 
of  this  kind,  in  which  the  head  of  the  bone  had  become  absorbed; 
but,  as  you  will  see  in  the  specimen  I  now  show  you,  the  cancellated 
tissue  of  the  head  of  the  bone  is  supplied  with  blood  through  vessels 

1  Diseases  of  Bones  and  Joints,  1881. 


82  EXPERIMENTAL  SURGERY. 

passing  along  the  round  ligament  and  through  the  fibrous  structure 
uniting  it  with  the  trochanter  major." 

The  fractured  head  of  the  humerus,  deprived  of  all  vascular 
supply,  unites  by  bone  like  any  other  fracture,  because  the  anatomi- 
cal relations  about  the  seat  of  fracture  are  such  that  coaptation  is 
maintained  without  difficulty.  Fractures  within  the  capsule  of  the 
hip-joint  will  follow  the  same  rule  as  soon  as  the  surgeon  can  suc- 
cessfully combat  the  obstacles  which  cause  displacement.  The  last 
cause,  atrophy  of  bone,  is  the  weakest  argument  in  favor  of  non- 
union. Clinical  experience  furnishes  abundant  proof  that  in  persons 
suffering  from  fragilitas  ossium  fractures  not  only  unite,  but  unite 
very  promptly.  Mr.  Holmes,  in  his  System  of  Surgery,  quotes  from 
Gibson  the  case  of  a  youth  of  nineteen,  who  had  twenty- four  frac- 
tures, and  from  Esquirol  another  with  as  many  as  two  hundred 
fractures.  Earle  records  a  case  of  eight  fractures  in  a  child  of  ten 
years,  and  Flemming  observed  a  case  where  a  person  suffered  fifty- 
three  fractures  between  the  ages  of  one-and-a-half  and  twenty-five 
years.  In  all  of  these  cases  union  took  place  rapidly.  Gurlt  reports 
a  large  number  of  similar  cases.  He  states  very  distinctly  that  old 
age  does  not  retard  the  process  of  union,  as  has  been  erroneously 
supposed;  the  reparative  process  is  the  same  as  during  adult  life.1 

I  believe  non-union  is  more  frequently  observed  in  young, 
robust  persons  than  in  old  people.  I  have  seen  a  fracture  of  the 
femur,  at  the  junction  of  the  middle  with  the  upper  third,  in  an  old 
decrepit  man  suffering  at  the  same  time  from  locomotor  ataxia,  unite 
firmly  by  bone  in  less  than  six  weeks.  Fracture  of  the  lower  end  of 
the  radius  is  common  after  middle  life,  invariably  unites,  and  in  a 
remarkably  short  time.  Senile  osteo-porosis  is  a  condition  of  bone 
favorable  to  the  production  of  intermediate  callus.  Atrophy  of 
bone  facilitates  inflammatory  osteo-porosis,  an  event  which  always 
precedes  the  formation  of  callus.  Some  authors  mention  still  other 
causes  for  non-union,  as  the  presence  of  synovia  and  the  absence  of 
a  nidus  for  the  formative  material.  Both  of  these  conditions  simply 
remind  us  that  the  bones  are  not  in  apposition,  otherwise  they  have 
no  significance  in  preventing  union  by  bone.  From  this  short 
review  we  are  not  only  justified,  but  warranted,  in  asserting  that  the 
only  cause  for  the  non-union  in  cases  of  intra-capsular  fracture  is  to 

1  Italics  my  own. 


BONY   UNION  AFTER   INTRA-CAPSULAR   FRACTURE.  83 

be  found  in  our  inability  to  maintain  perfect  coaptation  and  immo- 
bilization of  the  fragments  during  the  time  required  for  bony  union 
to  take  place. 

XYII.    Bony  Union  after  Intra-Capsular  Fracture. 

In  a  circular  letter  I  addressed  to  prominent  surgeons  in  this 
country,  England.  France,  Germany,  and  Switzerland,  for  the  pur- 
pose of  ascertaining  the  prevailing  opinion  on  the  subject  of  bony 
union  after  intra-capsular  fracture,  I  asked  this  question:  "In 
your  opinion  does  bony  union  ever  occur  after  impacted  intra- 
capsular fracture  of  the  neck  of  the  femur,  and  under  what  circum- 
stances?" 

To  this  question  I  received  fifty  direct  replies.  The  opinions 
were  divided  as  follows:  Yes,  twenty-seven;  no,  eighteen;  doubtful, 
five.  It  is  a  significant  fact  that  the  replies  from  professors  of 
surgery  in  German  universities,  five  in  number,  were  without  excep- 
tion, in  the  affirmative,  while  the  greatest  diversity  of  opinion 
appeared  to  exist  in  our  own  country;  at  least  fifty  per  cent,  of  the 
correspondents  replied  with  an  emphatic  "No."  I  believe  the 
answers  received  reflect  correctly  the  sentiments  of  the  entire  pro- 
fession on  this  point.  If  we  add  the  five  doubtful  correspondents 
to  the  eighteen  negative,  we  have  nearly  fifty  per  cent,  who  do  not 
believe  it  possible  for  bony  union  to  take  place  within  the  capsule 
even  under  the  most  favorable  circumstances. 

I  consulted  the  text -books  and  monographs  on  this  subject  with 
about  the  same  result.  It  would  then  appear  that  nearly  one-half 
of  the  profession  still  doubt  the  possibility  of  union  by  bone  in  cases 
of  intra-capsular  fracture. 

Having  shown  that  there  are  no  anatomical  and  physiological 
impossibilities  present  to  prevent  osseous  union  after  intra-capsular 
fracture,  and  having  referred  to  a  number  of  reliable  and  well- 
authenticated  cases  of  this  kind,  I  will  quote  the  opinion  of  a  few 
recognized  authorities  on  this  subject. 

Sir  Astley  Cooper,  the  originator  of  the  controversy  on  this 
subject,  and  who  is  always  quoted  as  authority  on  the  negative  side 
of  this  question,  has  never  denied  the  possibility  of  union  by  bone, 
as  is  evident  from  what  he  says  on  page  137  of  his  work:1     "I  have 

1  Fractures  and  Dislocations. 


84  EXPERIMENTAL  SURGERY. 

only  met  with  one  in  which  a  bony  union  had  taken  place,  or  which 
did  not  admit  of  a  motion  of  one  bone  upon  the  other.  To  deny  the 
possibility  of  this  union  (bony  union),  and  to  maintain  that  no  excep- 
tion to  the  general  rule  can  take  place,  would  be  presumptuous, 
especially  when  we  consider  the  varieties  of  direction  in  which  a 
fracture  may  occur,  and  the  degree  of  violence  by  which  it  may  have 
been  produced."  He  enumerates  a  number  of  conditions  which 
would  maintain  permanent  apposition,  and  then  proceeds:  "Such  a 
favorable  combination  of  circumstances  is  of  very  rare  occurrence." 
At  the  time  this  was  written  the  process  of  repair  in  bone  was  but 
imperfectly  understood,  and  the  occurrence  of  impaction  within  the 
capsule  was  either  unknown,  or  its  importance  as  an  essential 
element  for  bony  union  was  not  appreciated. 

Heister,1  nearly  a  century  and  a  half  ago,  after  explaining  that 
the  frequency  of  non-union  in  cases  of  fractures  of  the  femoral 
neck  was  owing  to  the  difficulty  of  keeping  the  broken  ends  of  the 
bone  in  apposition,  makes  the  following  statement:  "If  an  instru- 
ment could  be  invented  which  would  keep  such  a  limb  so  extended 
that  during  the  cure,  or  at  least  during  the  first  two  or  three  weeks, 
it  could  be  kept  as  long  as  the  healthy  one,  there  would  be  hope 
that  the  fracture  could  be  cured  more  satisfactorily  than  has  been 
the  case  heretofore."  Since  we  have  learned  that  the  production  of 
the  intermediate  callus  requires  months  instead  of  weeks,  Heister 
would  have  to  modify  his  statement  by  greatly  extending  the  period 
of  time  required  for  maintaining  apposition. 

Desault,2  in  combating  the  popular  idea  of  insufficient  blood 
supply  as  a  cause  of  non-union,  states:  "The  head  of  the  bone 
separated  from  the  soft  parts,  and  attached  to  the  acetabulum  by 
the  round  ligament,  receives  a  sufficiency  of  nutriment  to  enable  it 
to  live  in  that  cavity;  for  there  is  no  instance  of  its  having  suffered 
mortification  in  consequence  of  a  fracture.  Why,  then,  should  it 
not  partake  of  the  properties  of  life,  and  particularly  of  the  faculty 
of  reunion  when  placed  in  regular  apposition  with  the  body  of  the 
bone  ?  " 

The    following   quotation  is  from  Syme:3    "But  none  of   the 

1  Chirurgie,  1747,  p.  193. 

2  A  Treatise  on  Fractures,  etc.     Edited  by  X.  Bichat;  translated  by  Chas. 
Caldwell,  1817. 

3  The  Principles  of  Surgery,  1832,  p.  261. 


BONY   UNION  AFTER  INTRA-CAPSULAR   FRACTURE.  85 

arguments,  which  have  been  adduced  to  prove  the  impossibility  of 
osseous  junction,  seems  to  be  conclusive,  and  though  the  small 
extent  and  mobility  of  the  broken  surfaces,  the  absence  of  vascular 
tissues  surrounding  the  fracture,  and,  perhaps,  also  the  presence  of 
synovial  fluid,  may  render  the  cure  very  difficult,  it  ought  still  to  be 
regarded  as  a  possible  occurrence." 

Richter1  claimed  that  bony  union  could  take  place  in  impacted 
fractures,  or  where,  by  careful  treatment,  apposition  and  retention 
were  fully  accomplished.  He  evidently  was  impressed  with  the 
importance  of  the  bone-producing  function  of  the  periosteiun,  as  he 
advanced  the  theory,  that,  in  fractures  of  the  neck  with  complete 
rupture  of  the  periosteum,  under  favorable  conditions,  bridges  could 
be  thrown  across  the  line  of  fracture  from  one  membrane  to  the 
other,  from  which  bone  could  be  produced. 

Dupuytren,2  in  criticising  the  treatment  followed  by  the  English 
surgeons,  and  alluding  to  the  secondary  displacements  following  the 
too  early  removal  of  retaining  apparatus,  gives  the  following  advice: 
"But,  if  these  surgeons  had  adopted  the  practice  of  the  Hotel-Dieu, 
in  keeping  their  patients  in  bed  for  eighty  or  even  a  hundred  days, 
they  would  have  been  convinced  of  the  practicability  of  reunion  and 
complete  cure  without  deformity."  And  again:  "I  can  only  say, 
for  my  part,  that,  if  the  specimens  at  the  Hotel-Dieu  are  insufficient 
to  satisfy  any  one  who  may  take  the  trouble  to  examine  them,  I  am 
at  a  loss  to  know  what  amount  of  evidence  such  sceptics  would 
require.  For  my  part,  I  regard  the  osseous  union  of  intracapsular 
fracture  as  demonstrated  and  placed  beyond  doubt." 

Malgaigne1  is  a  firm  exponent  of  Sir  Astley  Cooper's  teachings, 
and  yet,  after  the  most  critical  examination  of  specimens  for  which 
bony  union  was  claimed,  he  is  forced  to  acknowledge  that  three  of 
them  were  genuine.  He  says:  "  When  a  fracture  unites,  the  frag- 
ments do  not  undergo  such  enormous  losses  of  substance  as  we 
should  be  forced  to  admit  in  the  neck  of  the  femur;  and  in  Swain's 
case,  which  Sir  Astley  Cooper  himself  acknowledged  as  an  instance 
of  bony  union,  the  neck  of  bone  had  not  changed  its  form.     It  was 

1  Lehrbuch  von  den  Bruechen  unci  Verrenkungen  der  Knochen,  1833. 

2  On  the  Injuries  and  Diseases  of  Bones.  Edited  and  translated  by  F.  Le 
Gros  Clark,  1847. 

8  A  Treatise  on  Fractures.  Translated  from  the  French  by  John  H.  Pack- 
ard, 1859. 


86  EXPERIMENTAL   SURGERY. 

so  also  in  Stanley's  case;  and,  lastly,  one  femur  (No.  188),  in  the 
Mus6e  Dupuytren,  has  lost  nothing,  either  in  form  or  volume,  except 
as  the  result  of  very  trifling  displacement.  I  admit  that  these  three 
examples  demonstrate  quite  positively  the  existence  of  consolida- 
tion; but  I  cannot  say  the  same  of  the  rest."  Loss  of  substance 
and  change  of  direction  of  the  neck  can  no  longer  be  regarded  as 
evidence  against  the  existence  of  bony  union,  as  they  only  indicate 
the  presence  of  impaction  followed  by  interstitial  absorption,  the 
consequence  of  inflammatory  osteo-porosis. 

Nathan  R.  Smith,1  in  recommending  his  anterior  splint  in  the 
treatment  of  fractures  of  the  neck  of  the  femur,  expresses  his  con- 
victions as  follows:  "This  apparatus,  with  slight  modifications,  is 
applicable  to  all  fractures  of  the  femur.  To  none  is  it  more  appro- 
priate, and  in  none  has  it  accomplished  more  satisfactory  results, 
than  in  fractures  of  the  cervix,  the  events  of  which  are  so  justly 
regarded  as  an  opprobrium  of  surgery.  So  uniformly  has  non- 
union and  deformity  resulted,  that  eminent  surgeons  have  denied 
that  bony  continuity  is  ever  restored  within  the  capsule.  We  hope 
to  show  that  these  results  are  rather  the  consequence  of  insufficient 
treatment,  than  defect  in  the  reparative  power  of  nature." 

H.  H.  Smith2  advocates  the  possibility  of  bony  union  in  the 
following  language:  "That  osseous  union  has  been  seen,  cannot 
reasonably  be  doubted,  and  from  a  careful  analysis  of  the  seat  of 
fracture  in  these  cases,  I*  think  it  is  evident  that  there  are  a  com- 
paratively limited  number  of  cases  in  which  osseous  union  does 
occur;  and  I  suggest  that,  as  a  general  rule,  based  on  observation,  it 
will  be  found  that  the  nearer  a  fracture  is  situated  to  the  head  of 
the  bone,  or,  in  other  words,  the  shorter  the  upper  fragment,  the 
greater  will  be  the  possibility  of  osseous  union;  because  the  shorter 
the  upper  fragment,  the  greater  the  chance  that  the  vessels  which 
supply  it  with  blood  through  the  round  ligament  will  be  able  to 
furnish  it  with  an  amount  of  material  sufficient  to  enable  osseous 
union  to  take  place  by  a  deposit  of  bone  from  the  Haversian  canals." 

Samuel  Solly3  writes:  "If  you  can  diagnose  that  the  fracture 
is  an  impacted  fracture  of  the  cervix,  then  you  may  with  tolerable 

1  Treatment  of  Fractures  of   the  Lower  Extremity,  by  the  use  of    the 
Anterior  Suspensory  Apparatus,  1867. 

2  The  Principles  and  Practice  of  Surgery,  1863. 

3  On  Fractures  of  the  Neck  of  the  Thigh-Bone.     The  Lancet,  1867. 


BONY   UNION  AFTER   INTRA-CAPSULAR  FRACTURE.  87 

confidence  predict  complete  union  and  a  sound  limb.  I  have  shown 
by  reference  to  the  preparations  in  the  College  of  Surgeons'  Museum, 
and  also  in  our  own,  that  fractures  of  the  cervix  within  the  capsule 
will  unite,  though  not  so  frequently  as  those  without." 

Chelius1  claims  that  bony  union  may  have  been  observed  less 
frequently  in  England  than  on  the  Continent,  on  account  of  neg- 
lected treatment  in  cases  diagnosticated  as*  intracapsular  fractures. 

Erichsen,2  in  discussing  this  subject,  remarks:  "In  some  cases, 
however,  bony  union  takes  place.  This  may  happen  when  the 
cervical  ligament  remains  intact,  or  when  the  fracture  is  impacted." 

Holthouse3  says:  "Bony  union  in  this  fracture  (intra-capsular) 
is  rare,  and  by  some  has  been  considered  impossible ;  but  a  sufficient 
number  of  undoubted  cases  have  now  been  brought  to  light,  both  in 
Europe  and  America,  to  place  the  fact  beyond  a  doubt." 

Agnew,4  in  speaking  of  Astley  Cooper's  method  of  treatment  of 
intra-capsular  fractures,  remarks:  "  There  have  been  recorded  a 
sufficient  number  of  cases  of  bony  union,  after  what  was  believed  to 
be  intracapsular  fracture,  to  justify  a  hope  that  some  of  the  cases 
encountered  by  the  surgeon  may  have  a  similar  termination." 

Gant5  expresses  a  similar  opinion:  "  Bony  union  at  one  time, 
and  for  many  years,  thought  never  to  take  place,  does  assuredly  in 
some  rare  cases;  but  only,  it  would  seem,  when  the  capsular  ligament 
remains  entire,  or  the  fragments  are  impacted,  whereby  a  due  supply 
of  blood  can  be  speedily  established." 

Bryant0  makes  use  of  the  following  language:  "  In  the  impacted 
fractures  union  ought  to  be  looked  for  if  the  broken  fragments  are 
left  alone,  and  not  loosened  by  a  careless  and  too  curious  manipula- 
tion. In  the  purely  intracapsular  fractures,  union  may  take  place, 
osseous  in  many  cases,  fibrous  in  more." 

MacNamara7  affirms:  "I  believe,  if  you  can  keep  the  parts  at 
rest,  in  many  cases  of  intra-capsular  fractures,  union  of  the  ends  of 
the  bones  will  occur." 

1  Handbuch  der  Chirurgie,  B.  I.     S.  119. 

2  The  Science  and  Art  of  Surgery,  1869. 

3  Holmes'  System  of  Surgery,  1875,  vol.  ii.  p.  846. 

4  Principles  and  Practice  of  Surgery,  1878,  vol.  i.  p.  938. 
•'  The  Science  and  Art  of  Surgery,  1878,  p.  646. 

6  Principles  of  Surgery,  edited  by  J.  B.  Roberts,  1881. 

7  Diseases  of  Bones  and  Joints,  1881. 


88  EXPERIMENTAL   SURGERY. 

Koenig1  realizes  the  importance  of  impaction  in  the  reparative 
process,  as  may  be  seen  from  his  statement  that  intra-capsular  frac- 
tures heal  less  frequently  by  osseous  union  than  extracapsular 
fractures,  because  they  are  less  frequently  impacted. 

Hueter,2  who  classifies  fractures  of  the  neck  of  the  femur  into 
those  with  and  without  impaction,  regardless  of  the  attachment  of 
the  capsular  ligament,  lays  it  down  as  a  rule  that  impacted  fractures 
usually  unite  by  bony  union. 

Stimson,3  in  discussing  this  subject,  advances  the  following  as 
one  of  his  arguments  in  favor  of  the  possibility  of  bony  union: 
"  Even  if  we  disregard  all  existing  specimens  of  alleged  bony  union, 
the  possibility  of  such  union  must,  I  think,  be  admitted,  because  of 
the  demonstrated  fact  that  the  head  preserves  its  vitality,  and  has 
shown  its  ability  to  produce  granulations  and  bone;  the  former 
proved  by  the  examples  of  fibrous  union,  the  latter  by  eburnation  or 
condensation  of  its  spongy  tissue." 

I  will  close  the  list  of  witnesses  who  testify  to  the  possibility  of 
bony  union  after  intra-capsular  fracture,  by  quoting  the  last  sen- 
tences of  Jonathan  Hutchinson's  description  of  the  specimen  in  the 
Pathological  Museum  of  Leeds  Hospital:  "This  specimen  is  alluded 
to  by  Malgaigne  and  Hamilton,  as  if  it  were  of  doubtful  validity ;  but 
neither  of  them  had  probably  seen  it.  I  cannot  but  hope  that  the 
publication  of  these  life-size  drawings  of  the  bone  will  set  at  rest  all 
skepticism  as  to  the  possible  union  of  intra-capsular  fractures.  I 
trust,  also,  that  it  may  lead  to  greater  hopefulness  in  the  treatment 
of  these  accidents,  and  thus  to  more  systematic  care  in  securing 
coaptation." 

With  such  an  array  of  unprejudiced,  honest,  and  conscientious 
witnesses  before  us,  who  unanimously  and  most  positively  testify 
that  union  by  bone  can,  and  not  unfrequently  does  take  place,  we 
are  no  longer  warranted  in  denying  its  possibility.  The  number  of 
well-authenticated  specimens  has  been  gradually  increasing,  and  the 
knowledge  derived  from  clinical  observation  and  experimental  inves- 
tigations on  this  subject  during  the  last  few  years,  can  leave  no 
further  doubt  as  to  the  production  of  bony  callus  in  intra-capsular 

1  Lehrbuch  der  Speciellen  Chirurgie,  B.  II.  1879,  S.  857. 

2  Grundriss  der  Chirurgie,  B.  II.  1882,  S.  884. 

3  A  Treatise  on  Fractures,  1883,  p.  503. 


TREATMENT   OF  FRACTURE.  89 

fractures.  In  the  interest  of  science,  and  for  the  benefit  of  the 
patients,  this  controversy  ought  to  be  and  must  be  decided  in  favor 
of  the  affirmative,  and  then  the  profession  will  be  prepared  to  seek 
for  measures  which  will  secure  better  results. 

XVIII.     Treatment. 

In  no  other  fracture  are  the  indications  for  successful  treatment 
so  difficult  to  meet  as  in  fracture  of  the  neck  of  the  femur.  Every 
unprejudiced  surgeon  is  forced  to  admit,  that  the  usual  bad  result 
in  these  cases  is  owing  more  to  the  insufficiency  of  the  treatment 
employed  than  to  the  anatomico-pathological  conditions  of  the 
broken  bone.  The  causes  of  non-union  are  not  to  be  found  in 
the  bi-oken  bone,  but  in  the  difficulties  encountered  in  the  treatment. 
All  the  various  methods  of  treatment  suggested  and  practiced  have 
failed  in  securing  perfect  coaptation  and  uninterrupted  immobiliza- 
tion. In  all  intra-capsular  fractures  union  is  effected  by  the 
production  of  an  intermediate  callus,  from  the  broken  surfaces; 
nature's  splint,  the  external  callus,  for  well-known  anatomical 
reasons,  is  always  wanting,  hence  the  surgeon's  splint  has  a  more 
important  and  prolonged  application  than  in  fractures  in  other 
localities.  The  time  required  for  bony  union  to  take  place  in 
fractures  of  the  femoral  neck  is  an  unusually  long  one.  Gurlt 1  fixes 
the  time  at  from  fifty-six  to  two  hundred  and  seven  days,  and  the 
average  duration  at  eighty-four  days. 

Dupuytren  estimates  the  time  at  from  one  hundred  to  one 
hundred  and  twenty  days,  and  states  that  it  has  been  customary  at 
the  Hotel- Dieu  to  keep  these  patients  in  bed  at  the  hospital  for 
eighty  to  one  hundred  days.  There  can  be  no  doubt  that  many 
cases,  which  promised  well  from  the  beginning,  have  terminated 
unfavorably  by  abandoning  the  treatment  too  early.  To  prevent 
secondary  displacements,  the  retentive  measures  should  not  be 
removed  for  at  least  eighty  to  one  hundred  days.  In  deciding  upon 
a  course  of  treatment  to  be  pursued  it  is  important  to  make  a  dis- 
tinction between  impacted  and  non- impacted  fractures. 

In  impacted  fractures  the  fragments  have  been  placed  in  the 
best  possible  condition  for  bony  union  to  take  place,  and  the  object 
of  treatment  consists  simply  in  maintaining  the  mutual  penetration 

1  Knochenbrueche,  vol.  1.,  p.  381. 


90  EXPERIMENTAL  SURGERY. 

until  the  reparative  process  is  completed,  and  the  continuity  of  the 
bone  restored.  The  surgeon  must  be  satisfied  with  securing  consoli- 
dation of  the  broken  bone  in  the  position  in  which  it  has  been 
placed  by  the  accident.  Any  attempt  to  correct  the  deformity  is 
unjustifiable,  and  would  necessarily  result  in  loosening  of  the 
impaction,  an  event  which  would  almost  to  a  certainty  be  followed 
by  non-union.  Permanent  fixation  of  an  impacted  fracture  is  neces- 
sary for  the  following  reasons: 

1.  It  maintains  the  impaction.  2.  It  prevents  secondary 
shortening  and  eversion  during  the  stage  of  inflammatory  osteo- 
porosis. 3.  By  keeping  the  injured  parts  at  rest,  it  serves  as  a 
preventive  measure  against  the  accession  of  arthritis  and  para- 
arthritis.  4.  It  enables  the  patient  to  leave  the  bed  before  complete 
consolidation  of  the  fracture  has  taken  place. 

Extension  is  always  contra-indicated  in  these  cases,  as  it 
certainly  can  do  no  good,  and  may  result  in  irreparable  damage  by 
loosening  the  impaction.  The  best  dressing  to  accomplish  perma- 
nent fixation  is  a  plaster-of-paris  bandage.  To  insure  complete 
immobility  of  the  hip-joint,  the  bandage  must  include  the  injured 
limb  from  the  toes  upwards,  the  entire  pelvis,  and  the  sound  limb 
from  the  pelvis  to  at  least  as  far  as  the  knee.  For  the  purpose  of 
greater  durability  and  security  of  the  dressing,  a  tin  or  wood  splint 
can  be  incorporated  in  the  plaster  bandage.  In  the  application  of 
this  bandage  it  is  necessary  to  protect  all  prominent  bony  projections, 
more  especially  the  trochanter  major  over  the  affected  side,  with 
salicylated  cotton,  to  guard  against  excoriations;  a  flannel  bandage 
should  be  applied  next  to  the  skin.  During  the  application  of  the 
bandages,  and  until  the  plaster  sets,  it  is  necessary  to  place  the 
patient  on  a  pelvic  rest,  as  described  by  Bardeleben.  During  the 
setting  of  the  plaster,  it  is  important  to  make  lateral  pressure  over 
both  the  greater  trochanters,  in  order  to  secure  firm  support  to  the 
broken  bone. 

With  such  a  dressing,  the  patient  can  be  moved  without  fear  of 
disturbing  the  fracture,  and  in  a  few  days  he  can  leave  the  bed,  and 
in  a  few  weeks  can  walk  on  crutches,  if  deemed  necessary  for  the 
purpose  of  preventing  complications.  Unless  indications  arise,  it  is 
advisable  not  to  disturb  the  dressing  until  osseous  union  has  become 
sufficiently  firm  to  support  the  fragments.  It  is  particularly  danger- 
ous to  change  the  dressing  from  the  third  to  the  fifth  week,  as  during 


TREATMENT   OF  FRACTURE.  91 

this  time  the  inflammatory  osteo- porosis  has  a  tendency  to  loosen 
the  fragments.  I  am  satisfied  that  a  dressing  of  this  kind  is  vastly 
superior  to  any  splint  in  affording  comfort  to  the  patient  and  secur- 
ing the  best  attainable  result. 

In  the  treatment  of  non-impacted  fractures  the  same  principles 
should  govern  us  as  in  the  impacted  variety.  In  this  class  of  frac- 
ture, however,  another  important  indication  arises,  namely,  to  effect 
coaptation  of  the  fractured  ends ;  at  the  same  time  retention  is  more 
difficult  to  accomplish.  The  nearer  we  can  imitate  impaction,  the 
better  the  prospects  for  a  favorable  result.  If  we  could  keep  the 
broken  surfaces  in  perfect  coaptation,  and  maintain  retention  and 
immobility,  these  fractures  would  heal  in  the  same  way  as  impacted 
fractures.  That  these  indications  have  not  been  fulfilled  by  the 
usual  treatment  with  various  splints,  extension  by  weight  and  pulley, 
and  pelvic  belt,  nobody  can  deny.  Even  extra-capsular  fractures 
have  healed,  as  a  rule,  with  so  much  shortening  as  to  cripple  the 
patients  for  life,  while  the  results  after  intra-capsular  fractures  have 
almost  universally  been  so  bad,  that  many  of  the  most  distinguished 
surgeons  have  abandoned  all  active  measures,  limiting  their  treat- 
ment exclusively  to  palliation. 

Prominent  among  the  advocates  of  the  expectant  treatment  in 
intra-capsular  fractures,  I  will  mention  Sir  Astley  Cooper,  Velpeau, 
Langlet,  and  Lavacherie.  That  the  views  of  many  surgeons  on  this 
point  have  undergone  no  material  change  since  Sir  Astley  Cooper's 
time  is  apparent  from  more  than  one  recent  work  on  surgery.  I 
quote  verbally  from  Gant's  Surgery,  page  647:  "No  bony  union 
taking  place,  as  a  rule,  in  intra-capsular  fractures  of  the  neck  of  the 
femur,  it  will  generally  be  useless  to  adjust  the  fracture  and  apply 
any  retentive  apparatus  with  a  view  to  such  union;  and  the  more  so, 
in  proportion  to  the  years  of  the  patient." 

If  the  results  attending  the  different  methods  of  treatment  have 
been  so  bad  as  to  induce  men  of  the  highest  professional  attainments 
to  abandon  all  active  treatment  as  useless,  the  question  naturally 
arises:  Are  there  any  other  means  which  are  better  adapted  to 
accomplish  the  desired  result?  The  question  as  to  possible  bony 
union  after  intracapsular  fracture,  in  the  light  of  recent  researches, 
has  been  decided  in  the  affirmative,  and  a  more  practical  question 
arises:  How  can  it  be  obtained?     By  what  means  can  we  keep  the 


92  EXPERIMENTAL  SURGERY. 

fragments  in  mutual  coaptation  during  the  process  of  repair?  I 
would  suggest  the  following  points  in  the  treatment:  1.  Immediate 
reduction  and  coaptation  of  the  fracture  under  the  influence  of  an 
ansesthetic.  2.  Fixation  with  a  plaster-of-paris  splint.  3.  Lateral 
pressure.     4.  Direct  fixation  of  fragments  by  bone-pegs. 

i.     Immediate  Reduction  and  Coaptation. 

Extension  by  means  of  the  weight  and  pulley  overcomes  the 
shortening  only  gradually,  and  seldom  completely,  at  the  same  time 
it  necessitates  the  recumbent  position  for  a  long  time,  and  thus 
exposes  the  patient  to  all  the  risks  and  inconveniences  incident  to 
such  position.  If  the  patient  is  placed  thoroughly  under  the  influ- 
ence of  an  anaesthetic,  muscular  action  is  temporarily  annihilated, 
and  the  limb  can  be  extended  at  once  to  its  natural  length,  while 
coaptation  can  be  effected  at  the  same  time. 

The  advantages  arising  from  immediate  reduction  and  coapta- 
tion are  the  following:  1.  The  untorn  portions  of  the  joint 
structures  are  replaced  at  once  into  their  normal  relations;  a  pro- 
cedure which  cannot  fail  to  influence  favorably  the  circulation  in 
vessels  which  may  have  escaped  injury.  2.  The  sharp  and  irregular 
margins  of  the  broken  surfaces  act  as  irritants  to  the  surrounding 
soft  tissues;  inmiediate  reduction,  by  placing  the  bones  at  once  in 
mutual  coaptation,  acts  as  a  preventive  against  the  supervention  of 
undue  inflammation  in  and  around  the  hip-joint.  3.  With  coapta- 
tion the  process  of  repair  is  initiated  at  once,  the  blood  and  exudation 
material  between  the  fragments  act  as  a  temporary  cement  substance, 
and  at  the  same  time  serve  a  useful  purpose  in  re-establishing  the 
interrupted  circulation.  4.  Perfect  reduction  and  coaptation  prevent 
muscular  spasms  and  diminish  pain. 

2.     Fixation. 

Having  reduced  the  fracture,  retention  should  be  maintained 
in  a  similar  manner  as  in  impacted  fractures;  with  the  exception, 
however,  that  eversion  should  be  carefully  corrected.  The  plaster- 
of-paris  splint  is  applied  as  for  impacted  fracture,  only  that  over  the 
trochanter  major  of  the  injured  side  a  fenestrum,  about  two  inches 
wide  and  four  inches  long,  is  left  open  for  the  purpose  of  applying 
lateral  pressure. 


TREATMENT   OF  FRACTURE.  93 

3.     Lateral  Pressure. 

Many  fractures  of  the  femoral  neck  are  kept  from  becoming 
displaced  for  a  variable  period  of  time  by  interlocking  of  the 
denticulated  broken  surfaces,  a  condition  which  has  been  called  by 
Bigelow  "rabbeting."  Believing  that  the  surgeon  should  imitate 
the  reparative  resources  of  nature  wherever  it  is  possible  to  do  so,  it 
appears  to  me  that  artificial  rabbeting  could  often  be  produced  by 
lateral  pressure.  The  fractured  surfaces  being  placed  as  accurately 
as  possible  opposite  each  other,  lateral  pressure  would  cause  perfect 
coaptation  and  a  mutual  interlocking  of  the  fragments.  Lateral 
pressure,  applied  with  this  view,  would  be  one  of  the  most  reliable 
means  to  prevent  secondary  lateral  and  longitudinal  displacements. 
Pressure,  to  be  effective,  must  be  applied  in  the  direction  of  the 
broken  neck,  that  is,  over  the  trochanter  major,  and  in  such  a 
manner  as  not  to  interfere  with  the  superficial  circulation.  Pressure 
with  belts  and  strips  of  adhesive  plaster  encircling  the  whole  pelvis, 
can  exert  but  little  influence  on  the  fractured  bone,  at  the  same  time 
it  impedes  the  superficial  circulation. 

With  the  fenestrated  plaster-of-paris  splint,  pressure  can  be 
applied  directly  over  the  trochanter  major,  by  placing  a  well- 
cushioned  pad,  with  a  stiff,  unyielding  back,  corresponding  in  size 
to  the  fenestrum,  in  the  opening  of  the  splint,  and  applying  the 
necessary  amount  of  pressure  by  means  of  a  Petit' s  tourniquet,  or 
some  other  similar  contrivance.  A  small  amount  of  pressure,  if  well 
directed,  would  be  sufficient  to  retain  the  fragments  in  apposition. 
By  removing  the  pad  from  time  to  time,  and  washing  the  parts  with 
dilute  alcohol,  there  would  be  no  danger  of  producing  excoriation. 
The  pad  could  also  be  made  smaller,  and  the  pressure  surface 
changed  as  often  as  necessary,  as  an  additional  precaution  against 
superficial  excoriations. 

Lateral  pressure  and  fixation,  however,  could  be  applied  more 
directly  and  advantageously  by  means  of  a  long,  sharp,  steel  pin, 
regulated  by  a  set-screw  passing  through  the  centre  of  a  curved 
steel  bar,  incorporated  in  the  plaster-of-paris  bandage  over  the  fen- 
estrum, in  such  a  way  that  the  sharp  point  of  the  pin  would  perfo- 
rate the  soft  parts  over  the  centre  of  the  bone  of  the  femoral  neck, 
and  by  penetrating  a  small  distance  into  the  bone,  would  secure 
perfect  immobility  of  both  fragments.     By  removing  the  steel  pin 


94 


EXPERIMENTAL  SURGERY. 


and  adjusting  the  pad,  this  instrument  can  be  used  for  applying 
ordinary  lateral  pressure.     (Figs.   18,  19.) 


Fig.  18.     Apparatus  for  Treating  Fracture  of  Neck  of  Femur. 


Fig.  19.     Apparatus  Applied;  Steel  Point  of  Instrument  Fixed  in  Trochanter 

Major. 


TREATMENT   OF  FRACTURE.  95 

Heine1  has  used  a  somewhat  similar  instrument  in  the  treat- 
ment of  ununited  fractures  of  the  femur  and  tibia.  The  superficial 
site  of  the  greater  trochanter  would  render  this  dressing  of  easy 
application,  and  from  the  absence  of  very  sensitive  structures,  the 
pain  inflicted  would  not  be  as  severe  as  in  using  Malgaigne's  hooks 
for  fracture  of  the  patella.  Undue  inflammation  of  the  soft  parts 
coidd  readily  be  avoided  by  the  use  of  antiseptic  precautions.  It 
would  probably  not  be  necessary  to  continue  this  treatment  for  more 
than  two  to  four  weeks,  when  the  ordinary  pad  for  lateral  pressure 
could  be  substituted  for  the  steel  pin. 

4.    Direct  Fixation  by  Bone-Pegs. 

Apposition  of  the  fractured  ends  could  be  secured  and  main- 
tained with  the  greatest  degree  of  accuracy  by  measures  which  are 
calculated  to  operate  directly  upon  the  fragments.  Such  measures 
have  been  successful  on  other  joint  fractures,  where  the  usual 
prescribed  methods  of  treatment  had  failed  in  effecting  union  by 
bone.  In  the  case  of  fracture  of  the  femoral  neck,  however,  the 
injured  parts  are  so  inaccessible  as  to  exclude  the  propriety  of  any 
cutting  operation  for  the  purpose  of  exposing  the  fragments  to  view 
and  securing  apposition  through  the  wound.  At  the  same  time,  this 
injury  is  limited  almost  exclusively  to  a  class  of  patients  whose  gen- 
eral condition  would  forbid  an  operation  of  such  magnitude  for  such 
a  purpose.  If,  however,  an  operation  could  be  devised  which  would 
be  devoid  of  immediate  or  remote  danger  to  life,  that  would  not 
incur  any  loss  of  blood,  nor  add  to  the  suffering  of  the  patient,  and 
at  the  same  time  would  render  substantial  aid  in  maintaining  perma- 
nent apposition  of  the  fragments,  then  our  prospects  for  securing 
better  results  would  indeed  become  more  encouraging.  I  believe 
we  have  such  an  operation  in  subcutaneous  drilling  of  the  neck  of 
the  femur,  and  nailing  the  fragments  together  by  means  of  a  bonc- 
Peg- 

The  observations  of  Volkmann  and  Heine  have  shown  that 
driving  ivory-pegs  into  osteo-porotic  bones  will  produce  an  osteo- 
plastic inflammation  and  osteo-sclerosis.  The  operations  of  drilling 
and  insertion  of  bone-pegs  have  been  resorted  to  for  a  long  time,  for 

1  Ueber    operative    Behandlung    der  Pseud-arthrosen,  Verh.  d.  Deutsch. 
Gesollsch.  far  Chirurgie,  1877,  p.  220. 


»b  EXPERIMENTAL  SURGERY. 

the  purpose  of  promoting  the  formation  of  callus  in  cases  of  ununited 
fractures,  and  it  is  only  reasonable  to  assume  that  the  same  opera- 
tions would  have  a  similar  effect  in  recent  fractures.  The  operation 
offers  no  great  technical  difficulties  in  its  execution,  and  if  done 
under  strict  antiseptic  precautions,  does  not  expose  the  patient  to 
any  additional  risks. 

The  idea  of  immobilizing  fractures  by  nailing  the  ends  of  the 
broken  bone  together  is  not  a  new  one.  It  is  alluded  to  by  David 
Prince,1  in  treating  of  the  subject  of  ununited  fractures,  when  he 
says:  "Perhaps  a  bone  might  be  drilled  through  both  fragments, 
and  held  in  apposition  by  a  rivet  of  one  of  these  metals.  The  pres- 
ence of  the  rivet  after  the  completion  of  the  healing  process  would 
do  no  harm,  and  if  a  permanent  discharge  should  be  the  result,  the 
metal  could  be  readily  removed." 

As  yet  a  discrepancy  of  opinion  prevails  as  to  the  future  fate 
of  bone-  and  ivory-pegs  when  imbedded  in  living  bone.  Trendel- 
enburg 2  operated  for  a  very  oblique  ununited  fracture  of  the  femur 
at  the  junction  of  the  lower  with  the  middle  third,  by  fixing  the 
fragments  with  an  ivory-peg,  He  had  an  opportunity  to  examine 
the  specimen  two  and  a  half  years  after  the  operation.  The  frac- 
ture was  firmly  united,  and  the  ivory-peg  was  found  intact  in  the 
bone  tissue,  having  undergone  no  change  whatever,  except  that  a 
portion  which  had  projected  into  the  knee-joint  had  become  detached, 
and  was  found  imbedded  in  a  cyst  in  the  interior  of  the  joint,  sur- 
rounded by  giant  cells. 

Riedinger3  made  a  similar  observation.  Introducing  ivory-  or 
bone-pegs  into  the  bones  of  animals,  he  found  them  after  a  variable 
period  of  time  either  entirely  unchanged,  or  only  slightly  diminished 
in  size.  The  diminution  in  size  appeared  to  be  in  proportion  to  the 
vascularity  of  the  living  bone.  The  growth  of  the  bones  thus  treated 
was  stimulated,  as  was  shown  from  an  increase  in  their  length  as 
compared  with  the  opposite  bones. 

Bidder4  found  that  by  boring  a  hole  in  the  spongiosa  of  the 
epiphysis  of  the  long  bones  in  old  rabbits,  into  the  lower  end  of  the 

1  Plastics  and  Orthopedics,  1871,  p.  220. 

2  Ibid. 

3  Virchow  u.  Hirsch's  Jahresbericht,  1881,  vol.  ii.  p.  333. 

4  Exper.  Beitrage  u.  Anat.  Untersuchungen  d.  Knochengewebe,  etc.,  Archiv 
f.  Klin.  Chir.     B.  XXII.  p.  155. 


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nt   of   lev; 
7) 


TREATMENT   OF  FRACTURE.  97 

femur  for  example,  that  no  regeneration  of  bone  took  place,  the  loss 
of  substance  being  replaced  by  fibrous  and  myeloid  tissue.  In 
young  adult  rabbits  a  slight  attempt  at  regeneration  was  manifested. 
The  process  of  regeneration,  however,  was  increased  by  driving  ivory- 
pegs  into  the  perforations,  or  by  injecting  iodine  or  lactic  acid. 

Brainard1  taught  that  simple  perforation  of  bone  increased  the 
formation  of  callus,  while  insertion  of  ivory,  wooden,  or  metallic 
pegs  not  only  diminished  it,  but  with  few  exceptions  produced 
absorption  of  bone. 

Yolkmann 2  treated  a  pseud-arthrosis  of  the  femur  by  excision 
of  the  fractured  ends,  and  immobilized  the  fracture  by  driving  a  peg 
made  of  a  piece  of  fresh  bone,  taken  from  another  patient,  into  the 
medullary  cavity  of  both  ends.  The  fracture  united  and  the  trans- 
planted piece  was  not  seen  again. 

Riedingers s  experiments  on  animals  have  shown  that  ivory-  and 
bone-pegs  implanted  into  bone  increase  the  nutrition  of  the  bone, 
and  remain  without  giving  rise  to  any  undue  irritation,  and  are 
finally  partially  or  completely  absorbed.  Metallic  substances 
remain  firmly  imbedded.  Wood  and  rubber  invariably  gave  rise  to 
suppurative  inflammation.  Clinical  experience  and  experimental 
investigations  have  sufficiently  demonstrated  that  bone-  and  ivory- 
pegs,  if  implanted  under  antiseptic  precautions,  do  not  act  as  for- 
eign bodies,  and  never  give  rise  to  suppuration;  and  can,  therefore, 
be  safely  employed  in  securing  accurate  coaptation  of  recent  frac- 
tures, if  this  is  deemed  desirable  and  necessary,  and  not  attainable 
by  simpler  measures.  It  has  also  been  shown  that  these  pegs  pro- 
duce osteoplastic  inflammation,  and  thus  materially  hasten  the 
process  of  repair. 

The  operation  of  direct  immobilization  of  the  fragments  by 
means  of  bone-  or  ivory-pegs  is,  therefore,  particularly  adapted  to 
the  treatment  of  intra-capsular  fractures,  whenever  it  is  decided 
to  make  every  legitimate  attempt  to  secure  union  by  bone.  A  some- 
what similar  operation  has  been  performed  several  times  for  the 
purpose  of  relfeving  the  pain  incident  to  pseud-arthrosis,  following 
fractures  of  the  femoral  neck.     Before  the  introduction  of  antiseptic 

■Treatment  of  Ununited  Fractures,  Trans.  Am.  Med.  Assoc.  18f)H. 

-  Debet    Pseud-arthrosen    der    Vorderarm    Knochen.  Verb.   d.   Deutsch. 

t.  (Mr.,  ii.  1881,  p.  167. 
3  Verhandl.  d.  Deutschen  Gesellsch.  f.  Chir.,  1877,  p.  134. 

7 


98  EXPERIMENTAL   SURGERY. 

surgery,  Von  Langenbeck1  operated  by  exposing  the  greater  tro- 
chanter, and  passing  a  silvered  drill  through  it  into  the  upper 
fragment  so  as  to  secure  apposition.  The  fracture  was  oblique  and 
intracapsular  in  an  aged  female.  The  operation  was  followed  by 
destructive  inflammation,  hospital  gangrene,  and  death.  Lister 
operated  in  a  similar  manner,  but  under  the  protection  of  antiseptic 
surgery;  and  secured  a  good  result  by  a  short  fibrous  union.2  In 
this  case,  however,  it  appears  that  the  upper  fragment  was  not  trans- 
fixed by  the  screw.  Koenig3  repeated  Langenbeck' s  operation 
under  antiseptic  precautions,  and  secured  a  favorable  result. 

My  experiments  on  animals'  have  satisfied  me  that  it  is  not 
always  an  easy  task  to  find  the  upper  fragment  with  the  drill,  and 
perforate  it  at  the  proper  point.  To  overcome  this  difficulty,  it  has 
been  suggested  by  Trendelenburg,4  to  expose  the  seat  of  fracture  by 
a  small  incision  from  behind,  and  after  forcibly  abducting  the  limb, 
perforate  the  lower  fragment  from  within  outward;  then,  by  rein- 
serting the  drill  from  without  inward,  guided  by  a  finger  in  the 
wound,  after  straightening  the  limb,  to  transfix  the  upper  fragment. 
A  silver  screw  is  inserted  in  the  hole  made  by  the  drill,  and  the  two 
fragments  are  screwed  together.  The  screw  is  to  be  removed  after 
two  weeks.  For  the  purposes  for  which  we  have  urged  the  opera- 
tion, Trendelenburg's  advice  is  too  severe  and  dangerous.  By 
using  bone-  or  ivory-pegs  no  disastrous  results  would  follow  in  the 
event  the  peg  should  miss  the  upper  fragment  and  be  driven  into 
the  joint. 

Trendelenburg's  case  and  my  experiments  on  animals  furnish 
positive  proof  that  bone-  and  ivory-pegs  driven  into  the  interior  of 
joints  do  not  give  rise  to  any  serious  results.  The  operation  of  drill- 
ing the  femoral  neck  and  the  subsequent  insertion  of  the  ivory-peg 
is  facilitated  by  placing  the  limb  in  its  natural  position  and  securing 
it  by  the  plaster-of-paris  dressing.  The  drilling  is  done  through 
the  fenestrum  over  the  greater  trochanter  in  the  plaster  splint,  by 
sliding  the  skin  and  making  a  passage  for  the  drill  through  the 
soft  tissues  down  to  the  bone  with  a  tenotome,  at  a  point  correspond- 
ing to  the  centre  of  the  base  of  the  femoral  neck,  and  drilling  in  the 

1  Verhandlungen  d.  Deutschen  Gesellsch.  f.  Chirurgie,  1878,  p.  92. 

2  MacCormac,  Antiseptic  Surgery,  1880,  p.  200. 

3  Verhandlungen  d.  Deutschen  Gesellsch.  f.  Chirurgie,  1878,  p.  93. 
*  Idem. 


TREATMENT   OF  FRACTURE.  99 

direction  of  its  axis  toward  and  into  the  femoral  head.  The  length 
of  the  bone-  or  ivory-peg  should  correspond  to  the  distance  between 
the  outer  surface  of  the  greater  trochanter  and  the  centre  of  the 
femoral  head.  The  advantages  arising  from  the  treatment  as 
suggested  above  would  be: 

1.  The  most  perfect  degree  of  coaptation  and  immobilization 
of  the  fragments. 

2.  The  patient  could  be  placed  in  any  position  in  bed,  or  even 
be  taken  out-doors  as  soon  as  the  dressing  is  applied,  thus  effectually 
preventing  excoriations  and  the  diseases  incident  to  prolonged  con- 
finement to  bed  in  the  recumbent  position. 

I  do  not  advise,  of  course,  that  all  the  means  suggested  should 
be  called  into  use  in  every  case.  When  the  general  condition  of  the 
patient  is  such  as  to  preclude  any  possibility  of  obtaining  a  good 
result,  the  severer  ^measures,  which  aim  at  accurate  adjustment  and 
immobilization,  are  not  to  be  used.  In  such  cases,  it  is  only  neces- 
sary to  adjiist  the  parts  as  accurately  as  possible,  and  apply  the 
plaster-of-paris  dressing,  which,  by  keeping  the  parts  at  rest,  secures 
for  the  patient  the  greatest  degree  of  comfort,  and,  moreover,  does 
not  exclude  the  possibility  of  recovery  by  the  formation  of  a  short 
ligamentous  union.  If  the  patient's  health  is  fair,  and  the  symptoms 
are  such  as  point  to  the  existence  of  the  fracture  within  the  cap- 
sule, then  we  are  justified  in  resorting  to  the  means  which  will  insure 
the  greatest  accuracy  in  the  approximation  of  the  parts,  and  thus 
furnish  nature  with  the  only  known  means  by  which  she  can  restore 
the  continuity  of  the  bone. 


EXPERIMENTAL  RESEARCHES  ON  CICATRIZATION 
IN  BLOOD-VESSELS  AFTER  LIGATURE.1 


Skillful  treatment  of  haemorrhage  is  an  infallible  criterion  of 
good  surgery.  Dieffenbach  has  well  said,  "  From  the  behavior  of  a 
surgeon  in  cases  of  severe  haemorrhage  are  we  able  to  judge  of  what 
metal  he  is  made."  The  mechanical  measures  employed  in  the 
management  of  haemorrhage  have  at  all  times  constituted  subjects 
of  special  interest  to  surgeons.  Presence  of  mind,  a  steady  hand, 
prompt  action,  an  accurate  anatomical  knowledge,  familiarity  with 
the  various  haemostatic  agents,  and  clear  ideas  on  the  process  of  cica- 
trization in  vessels,  are  prerequisite  conditions  of  success  in  the 
treatment  of  the  most  frequent,  and,  at  the  same  time,  the  most 
alarming  emergency  which  presents  itself  to  the  surgeon — haemor- 
rhage. 

Ignorance,  hesitation,  and  timidity,  in  the  event  of  sudden, 
unexpected,  and  alarming  haemorrhage,  only  too  often  mean  death; 
while,  on  the  other  hand,  the  exercise  of  skill  founded  on  knowledge 
is  often  the  means  of  saving  human  life  under  the  most  desperate 
circumstances.  For  the  benefit  of  suffering  humanity,  fear  of  haem- 
orrhage has  deterred  pretenders  from  performing  bloody  operations, 
which  has  left  the  cultivation  of  the  field  of  operative  surgery  to 
men  of  skill  and  science. 

Perhaps  no  branch  of  surgery  has  reached  a  higher  degree  of 
perfection  than  the  treatment  of  injuries  and  diseases  of  the  blood- 
vessels. The  bold  operations  which  have  characterized  the  present 
era  of  surgery  owe  their  inception  and  their  legitimacy  to  the  aseptic 
ligature.  The  aseptic  ligature  and  the  antiseptic  treatment  of 
wounds  have  rendered  secondary  haemorrhage  an  exceedingly  rare 
accident  after  operations.  Every  surgeon  of  the  late  war  of  the 
Rebellion  is  painfully  aware  of  the  frequency  with  which  secondary 
haemorrhage  occurred  after  gunshot  injuries  or  any  of  the  capital 
operations. 

1  Read  before  the  American  Surgical  Association,  1884. 

101 


102  EXPERIMENTAL  SURGERY. 

Billroth  reported  twenty-three  cases  of  ligation  of  large  arteries 
after  gunshot  wounds,  and  of  this  number  in  seven,  or  30.4  percent., 
secondary  haemorrhage  took  place.  Porta  collected  six  hundred 
cases  of  ligation  of  large  arteries,  including  the  aorta,  innominata, 
carotid,  subclavian,  axillary,  common  iliac,  external  iliac,  and  femoral ; 
of  this  number  seventy-five,  or  12.5  per  cent.,  were  followed  by  sec- 
ondary hemorrhage.  Pilz  has  published  a  table  of  ligation  of  the 
common  carotid  artery  where  the  operation  was  done  one  hundred 
and  fifty-eight  times  for  haemorrhage;  of  these  cases  thirty-five,  or 
33.5  per  cent.,  suffered  from  secondary  haemorrhage,  which  proved 
fatal  in  sixteen,  or  15  per  cent. 

How  different  the  results  of  to-day!  An  artery  is  ligated,  the 
ligature  is  cut  short,  the  wound  heals  by  primary  union,  and  perma- 
nent obliteration  of  the  vessel  is  the  rule.  The  aseptic  ligature, 
wherever  and  whenever  it  can  be  applied,  has  almost  entirely  dis- 
placed all  other  haemostatic  agents,  and  is  now  universally  acknowl- 
edged as  the  safest  and  most  reliable  measure  in  securing  provisional 
and  definitive  closure  of  vessels.  Like  all  material  improvements, 
it  has  met  with  opposition,  but  a  more  extended  trial  has  silenced 
criticism.  Every  surgeon  should  be  in  possession  of  clear  and  defi- 
nite ideas  of  the  processes  which  nature  employs  in  effecting  cica- 
trization in  blood-vessels  after  ligature,  so  as  to  qualify  him  to  select 
and  apply  the  various  haemostatic  agents  intelligently,  and  to  measure 
their  effect  by  well-defined  anatomico-pathological  principles. 

This  subject  has  for  a  long  time  furnished  a  fertile  field  for 
theoretical  speculations,  pathological  investigations,  and  experimen- 
tal research. 

For  more  than  forty  years  the  doctrine  has  been  prevalent  that 
definitive  closure  of  a  vessel  after  ligature  is  invariably  due  to  the 
formation  and  organization  of  a  thrombus.  This  doctrine  is  still 
taught  by  many  of  our  teachers  and  recent  text-books  on  surgery. 
The  object  of  this  paper  is  to  disprove  this  assertion,  and  to  establish 
the  fact  that  the  production  of  the  intravascular  cicatrix  is  always 
the  result  of  proliferation  of  the  stable  connective-tissue  cells  and 
endothelia  of  the  walls  of  the  vessel,  independently  of  the  formation 
of  a  thrombus.  The  various  theories  which  have  been  advanced  to 
explain  the  process  of  obliteration  in  vessels  will  be  briefly  mentioned 
in  their  proper  order,  and  the  results  of  different  methods  of  experi- 


HISTORY   OF   THE   LIGATURE.  103 

mentation  will  be  described,   and,  finally,  the  results  of   my  own 
experimental  work  will  be  noticed. 

I.    History  of  the  Ligature.1 

For  a  better  elucidation  of  our  subject  it  is  necessary  to  briefly 
pass  in  review  the  history  of  the  ligature,  as  it  will  reflect  in  a  true 
light  the  pathological  ideas  entertained  by  surgeons  at  different 
times  regarding  its  immediate  and  remote  effects  in  arresting  the 
circulation  in  a  vessel  after  ligation. 

The  history  of  the  ligature  has  been  variable  and  eventful,  and 
has  always  been  intimately  connected  with  the  history  of  surgery, 
ever  constituting  a  reliable  barometer  indicating  the  status,  the  rise 
and  fall,  in  the  art  and  science  of  surgery.  Its  use  as  a  haemostatic 
agent  was  not  the  result  of  reasoning  or  logical  deduction,  but  was 
prompted  by  instinct.  It  was  used  and  described  long  before  the 
circulation  of  the  blood  was  discovered.  The  discovery  of  the  circula- 
tion, anatomico-pathological  investigations,  experimental  researches, 
and  clinical  observations  have  all  contributed  in  rescuing  this  invalu- 
able agent  from  the  dark  domain  of  empiricism,  and  have  secured 
for  it  a  position  as  a  remedial  agent  second  to  none  in  points  of 
importance,  reliability,  and  frequency  of  use. 

The  first  account  of  the  application  of  a  ligature  for  the  pur- 
pose of  preventing  haemorrhage  is  given  by  Sus'rutas,  a  disciple  of 
the  divine  Dhavantari,  in  his  Ayur  Vedas  (1500  B.  C),  who  tied  the 
umbilical  cord  in  newly-born  infants,  with  a  string,  eight  inches 
from. the  navel,  previous  to  cutting  it.  A  number  of  writers,  among 
them  Platner,  Holtze,  Langenbeck  and  Fischer,  allude  to  Hippocrates 
(460-377  B.  C.)  as  the  discoverer  of  the  ligature.  They  base  their 
opinion  on  the  following  passage  from  his  works,  translated  into 
Latin  by  Fassius:2  "  Sanguinem  e  renis  profluentem  sistunt  animi 
deliquium,  figura  aliorsum  tendens,  venae  interceptio,  linamentum 
contortum,  appositio,  deligatio." 

1  In  the  preparation  of  this  part  of  the  paper  I  am  greatly  indebted  to  the 
following  articles:  W.  Greifenberger,  Historisch-kritische  Darstellung  der 
Lehre  von  den  Unterbindung  der  Blutgefiisse.  Deutsche  Zeit.  f.  Chir.,  vol.  xvi. 
A.  Adamkiewiez,  Die  mechanischen  Blutstillungsrnittel  bei  verletzen  Arterien, 
von  Pare  bis  auf  die  reneste  Zeit.     Archiv  ftir  Klin.  Chir.,  vol.  xiv. 

2Hippocratis  medicorum  omnium  facile  principis  opera  omnia  quae 
exstant.     Frankf.  ii.  p.  1194. 


104  EXPERIMENTAL   SURGERY. 

Archigenes  (100  B.  C.)  made  free  use  of  the  ligature  after 
amputations.  Celsus  (30-25  B.  C,  45-50  A.  D.),  in  his  works,  refers 
to  the  ligature  as  a  well-known  remedy,  and  credits  an  obscure  phy- 
sician of  the  Alexandrian  school  with  its  discovery.  Celsus  used  the 
ordinary  linen  thread,  and  gave  particular  indications  for  its  use  and 
manner  qf  application.  In  speaking  of  the  operation  for  hydrocele, 
he  says : x  "  Nervus,  ex  quo  testiculus  dependet,  praecidendus ;  post 
id  venae  et  arteriae  ad  inguen  lino  deligandce  et  infra  vinculum 
abscindendae  sunt." 

Galen  (131-211  A.  D.),  who  although  no  practical  surgeon  him- 
self, was  yet  familiar  with  the  literature  of  that  day,  frequently 
mentions  the  ligature,  and  gives  particular  directions  to  apply  it  to 
the  proximal  end  of  the  bleeding  vessel.  For  ligature  material  he 
advises  silk  and  fine  catgut.  The  definite  closure  of  the  vessel 
he  attributes  to  the  action  of  the  tissues  surrounding  it,  as  is 
evident  from  the  following  quotation:2  "Quae  namque  caso  in 
abscisis  vasorum  partibus  coalescit,  ea  pro  opercula  est  ac  osculum 
eorum  claudit."  The  name  of  Antyllus  (350,  A.  D.)  occupies  such  a 
prominent  position  in  surgery  of  the  blood-vessels,  and  his  method 
of  procedure  in  cases  of  aneurism  is  so  familiar  to  every  student  in 
surgery,  that  more  than  a  simple  allusion  to  his  name  would  appear 
superfluous. 

Paulus  iEgineta  (625-690,  A.  D.)  treats  extensively  of  the  liga- 
ture, quoting  freely  from  the  writings  of  Celsus  and  Galen.  In 
practicing  ligation  of  vessels  as  a  therapeutical  measure  in  diverse 
affections,  he  passed  two  ligatures  beneath  the  vessel  with  the  aid  of 
a  needle,  cut  the  vessel  between  them,  and,  after  permitting  the 
requisite  amount  of  blood  to  escape,  closed  each  end  of  the  vessel 
separately.  Rhazes  (850-922,  A.  D.)  mentions,  as  a  last  resort  to 
arrest  haemorrhage  from  large  vessels,  the  ligature  which  he  made  of 
strong  linen  thread. 

The  prolific  writer,  Avicenna  (980-1037,  A.  D.),  disposes  of  the 
subject  of  ligation  of  vessels  briefly  thus:3  "  Quod  si  (sc.  vena)  fuerit 

1  Aul.  Corn.  Celsi  de  medicina  libri  octo,  quos  ad  Leon.  Targaa  recens,  de 
J.  H.  Waldeck,  Miinster,  1827,  p.  150. 

2  Claudii  Galeni  opera  omnia.  C.  G.  Kiihn,  Lipsiae,  1827,  T.  x.  L.  iii.  cap. 
xxii.  p.  941. 

3  Avicennae  Arabum  medicorum  principis  Canon  medicinse,  ex  Gerardi 
Cremonensis  versione  per  Fabium  Paulinum  Utinensem.  Venetiis  apud 
Juntas.     1595,  Lib.  iv.  Tract,  ii.  cap.  17. 


HISTORY   OF  THE   LIGATURE.  105 

pulsatilis,  turn  melius  est  ut  veles  eam  cum  filio  lini,  et  similiter  si 
fuerit  non  pulsatilis,  verum  tameu  multoties  elevatur  sanguis  ejus." 
Aneurisms  he  treats  in  accordance  with  the  teachings  of  Antyllus. 
He  limits  ligation  to  .arteries,  believing  that  bleeding  from  veins  is 
arrested  spontaneously  or  yields  to  the  use  of  the  customary 
styptics. 

Avenzoar  (1113-1162  or  1196,  A.  D.)  and  Averroes  (1198)  were 
familiar  with  the  ligature.  The  latter,  in  his  commentaries  on  the 
writings  of  Avicenna,  directs  that  in  performing  arteriotomy  the 
vessel  should  be  surrounded  by  two  ligatures  before  it  is  divided. 

Roland  (1252),  a  pupil  of  Roger,  of  Parma  (1214),  again  men- 
tions the  use  of  the  needle  in  applying  the  ligature,  a  practice  fol- 
lowed by  most  of  the  prominent  Italian  surgeons  at  that  time. 

Bruno,  of  Castel  Longobrugo  (1252),  pointed  out  the  difference 
between  arterial  and  venous  haemorrhage,  and  gave  the  advice,  in 
case  the  bleeding  could  not  be  arrested  by  any  other  means,  to  seize 
the  artery  or  vein  with  a  small  hook  and  carry  a  thread  with  a 
needle  around  the  vessel  and  tie  it  firmly. 

Guy  de  Chauliac  (1300-1363)  prefers  the  ligature  when  the 
artery  is  deeply  seated,  in  which  case  it  is  well  brought  into  view, 
and  that  end  is  firmly  tied  which  is  placed  towards  the  heart  or 
liver. 

Lenardo  Bertapaglia  (died  1460)  modified  the  intermediate 
ligation  by  passing  the  needle  armed  with  a  double  thread  not  under', 
but  through  the  artery,  tying  both  ligatures  firmly  over  each  other. 
Giovanni  Vigo  (1460-1520),  the  founder  of  the  school  of  surgery  in 
Rome,  was  acquainted  with  the  direct  or  immediate  ligature,  but 
gave  preference  to  the  intermediate  method  of  ligation. 

Alfonzo  Ferri  described  the  ligature  needle  used  at  that  time  in 
applying  the  intermediate  ligature,  which  was  about  three  inches  in 
length  and  curved  only  at  the  point,  with  the  eye  at  the  opposite 
end;  the  point  presented  four  sides  with  obtuse  angles,  so  as  to 
prevent  injury  to  the  vessel  or  its  adjacent  parts.  This  needle  was 
armed  with  a  double  ligature,  entered  about  two-thirds  of  a  fingers' - 
breadth  from  the  margin  of  the  wound,  was  passed  underneath  the 
vessel,  and  made  to  emerge  on  the  opposite  side  of  the  wound,  and 
the  ligature  firmly  tied  in  several  knots. 

Angelo  Bolognini  (1508),  founder  of   the  school  at  Bologna, 


106  EXPERIMENTAL  SURGERY. 

also   practiced   percutaneous   ligation  of   vessels,  using   silk   as    a 
ligature  material. 

Jacques  Houllier  (1493-1562)  in  wounds  of  the  arteries  relied 
on  digital  compression,  and,  when  this  failed  and  the  vessel  was 
deeply  located,  he  advised  that  it  be  gently  drawn  forward,  slightly 
twisted,  and,  after  ligating  both  ends,  divided  completely  at  the 
point  of  injury. 

In  Germany  we  find  the  first  mention  of  the  ligature  by  Hans 
von  Pfoloprundt.  Hieronymus  Brunschwig  (1450-1533)  practiced 
and  described  Bertapaglia's  method  of  ligation. 

Hans  von  Gersdorf  (1517),  a  military  surgeon  of  great  expe- 
rience, frequently  applied  the  intermediate  ligature  in  cases  of 
vessel  wounds,  but  preferred  styptics  and  the  actual  cautery  in 
amputations. 

Walter  Ryff  tied  the  proximal  end  of  the  vessel  by  isolating  and 
seizing  it  with  a  small  hook,  and  tying  firmly  with  a  silk  ligature. 

It  will  be  seen  that,  up  to  this  time,  the  ligature  had  for  the 
most  part  only  been  used  as  a  dernier  ressort  in  cases  of  wounds  of 
vessels,  while  styptics  and  the  actual  cautery  were  still  relied  upon 
as  the  safest  and  easiest  methods  of  arresting  haemorrhage. 

To  Ambrose  Par<§  (1517-1590)  surgery  owes  a  great  debt  of 
gratitude,  not  as  the  discoverer,  but  as  the  first  and  most  devoted 
champion  of  the  ligature.  Through  his  influence  and  untiring  zeal 
the  ligature  gradually  found  its  way  into  popular  favor,  and  dis- 
placed the  barbarous  treatment  by  styptics  and  cautery.  He  prac- 
ticed both  the  immediate  and  intermediate  ligation,  according  to 
the  location  of  the  vessel  and  circumstances  of  the  case.  His  first 
operations  were  performed  about  the  year  1552.  In  a  German 
translation  of  his  work  on  Surgery,1  published  in  the  year  1601,  I 
find  the  following  directions: 

"  Wo  auch  dieses  nicht  helffen  wolte,  so  muss  man  die  Haeffte, 
wofern  deren  eins  oder  mehr  vorgangen,  widerumb  auffthun,  und 
under  der  verletzten  ader,  gegen  ihrem  Anfang  oder  Wurtzel  zu,  mit 
einer  Nadel  und  Faden  durchhin  fuhren,  die  Ader  sampt  einer 
solchen  portion  oder  stucklein  Fleisches  desselbigen  Orts,  wie  viel 
nemlich  die  Gelegenheit  geben  und  erleiden  mag,  fassen  und 
zubinden.     Denn  also  hab  ich  offtmahlen  sehr  grosse  und  gewaltige 

1  Wundt  Artzney,  od.  Artzney  spiegell.  Translated  from  the  Latin  by 
Petr.  Offenbach,  Frankf.  1601,  p.  372. 


HISTORY   OF   THE   LIGATURE.  107 

Yerblutungen,  auch  in  denen  Wunden,  durch  welche  gantze  Arm 
oder  Schenkel  abgehawen  worden,  gestillt,  wie  an  seinem  ort  sol 
gemeldet  werden.  Dieses  aber  zn  verrichten,  werden  wir  vielrnal 
genotiget,  die  ganze  Haut,  so  liber  der  Ader  light,  auffzusckneiden 
und  zn  entblossen.  Denn  wenn  eine  anss  den  Bint  oder  Lufftadern 
des  Halses  ( Jugularium)  durchschnitten  were,  nnd  sich  die  beyde 
Ende,  beydes  hinanff  nnd  hinabwertz  von  einander  gezogen,  und 
also  verborsren  hetten,  muss  man  die  gantze  Haut  unter  welche  sie 
sich  verschlossen,  eroffnen,  die  Ader  entdecken,  mit  einer  Nadel  und 
Faden  darunter  hinfahren,  und  also  zusammenbinden,  wie  ich  dan 
selbst  vielmahl  sehr  glucklichen  und  wohl  verrichtet.  Du  solt  aber 
dieses  Bandt  oder  Faden  nicht  eher  auflosen,  biss  dass  du  sihest,  das 
die  Ader  mit  Fleisch  tiberwachsen,  und  der  Ader  Mundlochlein 
verstopfet  sey,  damit  das  Blut  nicht  widerumb  und  von  neuwen  zu 
rinnen  anfange." 

For  fear  of  secondary  haemorrhage  Par6  favored  the  ribbon 
ligature,  made  of  a  number  of  threads;  at  the  same  time  he  aimed  to 
include  portions  of  tissue  surrounding  the  vessel,  and  removed  the 
ligature  as  soon  as  healthy  granulations  covered  the  exposed  portion 
of  the  vessel.  He  used  the  ligature  with  a  view  simply  to  approxi- 
mate the  inner  walls  of  the  vessel  for  a  sufficient  length  of  time  for 
union  to  take  place,  when  its  further  presence  was  considered  use- 
less and  even  detrimental. 

The  contemporaries  of  Par6  were  slow  to  acknowledge  the 
superiority  of  the  ligature  over  the  rude,  but  time-honored  cautery. 
On  the  one  hand,  ignorance  and  prejudice  combined  in  checking 
progress;  while,  on  the  other,  it  must  be  acknowledged  that  Park's 
ligature  was  an  exceedingly  imperfect  thing,  which,  when  used 
according  to  his  directions,  could  not  fail  to  frequently  disappoint 
the  most  ardent  admirer.  It  required  centuries  to  establish  it  in  the 
confidence  of  the  profession. 

Jacques  Guillemeau  (1550-1 01 3),  Park's  pupil,  friend,  and 
successor,  labored  faithfully  and  earnestly  in  the  interest  of  the 
cause  of  his  illustrious  master.  He  was  one  of  the  first  to  resume 
the  operation  on  arteries  in  their  continuity  for  the  cure  of  aneurism. 
He  applied  the  ligature  on  the  cardiac  side,  opened  the  sac,  and 
allowed  it  to  heal  by  granulation. 

Pierre  Dionis  (died  17 IS)  states  that  at  his  time  the  cautery 
was  used    almost  exclusively  at  the  Hotel  Dieu  after  amputations, 


108  EXPERIMENTAL   SURGERY. 

although  he  resorted  to  the  ligature  frequently,  and  in  some 
instances  even  practiced  immediate  ligation.  In  1783,  Petit  (1654- 
1750)  writes  of  the  ligature:1  "La  ligature  cause  des  grandes 
douleurs,  des  tressaillements  convulsifs  et  quelque  fois  la  convulsion 
du  Moignon,  qui  souvent  est  mortelle  ou  par  ellememe  ou  parce- 
qu'elle  occasionne  l'h^morrhagie  par  les  mouvements  extraordinairs 
que  la  malade  ne  peut  s'empecher  de  faire." 

Fabricius  von  Hilden  (1560-1634)  and  Scultetus  (1595-1645) 
introduced  Parens  practice  into  Germany.  The  former  made  use  of 
the  hemp  ligature,  but  restricted  its  application  to  young  healthy 
persons. 

Cornelius  von  Solingen  (died  1692)  practiced  immediate  liga- 
tion after  the  example  of  Dionis.  Anton  Nuck  (died  1692)  only 
made  use  of  the  ligament  in  operating  for  aneurism  after  the  method 
of  Antyllus. 

In  England  the  ligature  was  introduced  by  Wiseman  (1566- 
1625)  and  was  eagerly  adopted  after  the  discovery  of  the  circulation 
by  Harvey  in  1619. 

Fabricius  ab  Aquapendente  (died  1620)  applied  two  ligatures 
to  arteries  and  divided  the  vessel  between  them,  so  as  to  allow  both 
ends  to  retract. 

Marcus  Aurelianus  Severinus  (1580-1656)  was  the  first  to  tie 
the  femoral  artery  near  Poupart's  ligament. 

Cesare  Magati  (1597-1647)  followed  the  advice  of  Galen  and 
Avicenna,  and  tied  the  vessels  only  on  the  cardiac  side. 

Kirkland  (1721-1798)  attributes  the  definitive  closure  of  vessels 
after  ligation  to  the  inherent  contractibility  of  the  vessel  wall. 

White  and  Aikin  expressed  a  similar  view,  as  becomes  apparent 
from  the  following  passage:  "That  the  arteries,  by  their  natural 
contraction,  coalesce  as  far  as  their  first  ramification."2 

John  Bell  (1760  -  1820)  concurred  in  this  view,  but  added 
another  important  element,  adhesive  inflammation  in  the  vessel  wall 
induced  by  the  ligature.3 

Larrey  (1766-1842)  observed  that  in  many  cases  after  ligation 
no  coagulum  formed,  and,  in  consequence,  asserted  that  definitive 

1  Mem  de  l'Acad.  Royale  des  Sciences,  1733,  p.  91. 

2  Cases  in  Surgery,  p.  171. 

3  Discourses  on  the  Nature  and  Cure  of  Wounds,  1800,  p.  109. 


HISTORY   OF   THE   LIGATURE.  109 

obliteration  of  the  vessel  can  take  place  independently  of  it,  and  is 
then  due  to  contraction  of  the  vessel  wall. 

Richerand  (1779-1840)  believed  that  the  ligature  brings  the 
inner  walls  of  the  vessel  in  contact,  and  that  direct  adhesion  takes 
place,  the  result  of  adhesive  inflammation. 

Garengeot  (1688-1759)  feared  the  cutting  through  of  the  liga- 
ture, and,  for  the  purpose  of  preventing  this  accident,  advised  the 
use  of  a  broad,  ribbon-like  ligature. 

Claude  Ponteau  (1725-1775)  abandoned  the  use  of  the  broad 
ligature,  but,  to  guard  against  the  same  evil,  included  within  the 
ligature  a  sufficient  amount  of  paravascular  tissue. 

Lorenz  Heister  (1683-1758)  used  a  stout  ligature,  and  tied 
over  a  small  cylinder  of  lint  to  prevent  premature  cutting  through 
of  the  ligature. 

J.  Z.  Platner  (1694-1747)  made  use  of  a  similar  contrivance, 
but  always  applied  a  double  ligature,  with  a  third  (reserve  ligature) 
on  the  cardiac  side,  to  be  tied  in  the  event  of  secondary  haemorrhage. 

Alexander  Monroe  (1697-1767)  protested  against  the  inter- 
mediate ligature,  and  emphasized  the  importance  of  direct  ligation. 
He  used  broad  ligatures,  and  tied  only  with  sufficient  firmness  to 
approximate  the  inner  walls  of  the  vessel. 

Wm.  Bromfield  (1712-1792)  isolated  the  artery,  drawing  it  out 
on  the  surface  of  the  wound  with  a  hook  of  his  own  construction, 
which  still  bears  his  name,  and  applied  a  flat  ligature. 

In  France,  Deschamps  (1740-1824)  advocated  the  superiority 
of  immediate  ligation  by  means  of  a  broad  ligature,  on  the  ground 
that  when  the  intermediate  ligature  is  used,  the  interposed  tissues 
disappear  very  rapidly,  leaving  the  ligature  loose  around  the  artery, 
thus  favoring  the  occurrence  of  secondary  hemorrhage. 

Abernethy  (1763-1831)  applied  a  double  ligature  in  tying  an 
artery  in  its  continuity,  and  divided  the  vessel  between  them,  claim- 
ing that  in  so  doing  he  was  able  to  relieve  the  tension  in  the  peripheral 
portion  of  the  vessel,  and,  at  the  same  time,  to  enable  both  ends  of 
the  artery  to  retract  into  the  tissues.  He  also  condemned  the  reserve 
ligature,  as  it  would  necessitate  more  extensive  isolation  of  the 
vessel,  thus  cutting  off  nutrition,  and  provoking  a  higher  degree  of 
inflammation  and  suppuration. 

August  Gottleib  Richter  (1742-1812)  introduced  the  immediate 
ligature  into  Germany. 


110  EXPERIMENTAL  SURGERY. 

On  Dec.  12,  1785,  John  Hunter  (1728-1793),  for  the  first  time, 
tied  the  femoral  artery  in  loco  prcedilectionis  for  popliteal  aneu- 
rism. He  applied  four  ligatures  at  short  interspaces,  of  which 
number  only  the  most  distal  one  was  tied  firmly;  the  remaining 
ligatures  were  tied  in  such  a  manner  that  the  lumen  of  the  proximal 
end  of  the  artery  represented  a  cone,  with  the  base  towards  the 
cardiac  side  of  the  vessel.  Hunter  anticipated  that  this  method  of 
operation  would  favor  the  formation  of  thrombus,  and  thus  afford 
additional  security  against  secondary  hemorrhage.  His  expectations, 
however,  were  not  realized,  as  secondary  hemorrhage  occurred  on 
three  different  occasions,  and  the  patient  did  not  recover  until  seven 
months  had  elapsed.  He  did  not  repeat  this  operation,  and  subse- 
quently used  only  one  ligature. 

Desault  accidentally  made  the  observation  that  in  the  ordinary 
method  of  ligation  with  the  round  ligature  the  two  inner  tunics  of 
the  artery  are  ruptured. 

This  fact  was  verified  by  Jones,  who,  in  1806,  made  a  series  of 
careful  experiments  to  determine  this  point.  The  classical  work  of 
Jones  exerted  a  potent  influence  in  establishing  the  claims  of  the 
ligature,  not  only  in  England  but  wherever  surgery  was  practiced. 
He  claimed  that  obliteration  of  an  artery  after  ligature  can  take 
place,  independently  of  the  formation  of  a  thrombus,  by  the  trau- 
matic inflammation  and  plastic  exudation  induced  by  the  ligature. 
In  his  experiments  on  animals  he  applied  several  ligatures  in  close 
proximity.  He  called  particular  attention  to  the  deleterious  effects 
of  suppuration  on  the  process  of  cicatrization  in  the  blood-vessels, 
and,  for  the  purpose  of  guarding  against  this  event,  advised  the 
removal  of  the  ligatures  immediately  after  they  had  ruptured  the 
internal  coats  or  before  suppuration  was  established.  He  believed 
that  provisional  closure  of  the  vessel  is  accomplished  by  the  lacerated 
tissues  within  the  lumen  of  the  vessel,  and  that  the  healing  process 
within  the  vessel  is  the  same  as  in  any  other  wound,  producing  the 
definite  obliteration.  In  tying  large  arteries  he  advised  the  double 
ligature  and  division  of  the  vessel  between. 

B.  Travers  adopted  the  views  promulgated  by  Jones,  but  sub- 
stituted the  temporary  for  the  momentary  ligature.  He  recommended 
the  removal  of  the  ligature  as  soon  as  plastic  inflammation  was  fully 
established,  and  before  suppuration  had  had  time  to  take  place. 
The  period  of  time  in  which  the  ligature  would  accomplish  this 


HISTORY   OF   THE   LIGATURE.  Ill 

object  he  placed  at  forty-eight  to  ninety  hours,  according  to  the  size 
of  the  vessel  which  had  been  ligated.  Jones  and  Travers  deserve 
to  be  called  the  discoverers  of  the  temporary  ligature  upon  a  scien- 
tific basis.  On  Feb.  14th,  1817,  Travers,  for  the  first  time,  put  his 
theory  into  actual  practice.  He  ligated  the  brachial  artery  for 
aneurism,  and  removed  the  ligature  after  fifty  hours.  The  case 
proved  successful.  The  next  case,  the  artery  being  the  same,  did 
not  terminate  so  favorably;  secondary  haemorrhage  set  in  and 
proved  fatal.  J.  Hutchinson's  case,  operated  on  in  a  similar  manner, 
also  terminated  in  death  by  recurring  haemorrhages. 

Sir  Astley  Cooper  applied  the  temporary  ligature  in  two 
instances;  the  results  not  meeting  his  expectations  he  abandoned  it. 
Among  the  most  formidable  opponents  of  the  temporary  ligature 
may  be  mentioned  Hodgson,  Vacca  Berlinghieri,  and  C.  J.  M.  Lan- 
genbeck,  who  claimed  that  it  was  impossible  to  determine  the  exact 
length  of  time  after  which  it  would  be  safe  to  remove  the  ligature, 
and  that  the  necessary  manipulations  for  the  removal  of  the  ligature 
would  interfere  with  the  prompt  healing  of  the  wound. 

In  Italy,  Antonio  Scarpa  (1747-1832)  strongly  advocated  the 
employment  of  the  temporary  ligature.  He  used  the  broad  ligature 
tied  over  a  cylinder  of  lint  for  the  purpose  of  bringing  and  keeping 
in  apposition  a  large  surface  of  the  inner  walls  of  the  vessel.  His 
experiments  have  demonstrated  that  obliteration  of  a  vessel  by 
adhesive  inflammation  can  and  does  take  place  without  division  of 
the  inner  coats.  He  compared  the  inner  surface  of  blood-vessels 
with  serous  membranes,  and  credited  it  with  the  property  of  under- 
going the  same  pathological  changes  when  subjected,  to  traumatism. 
He  ascertained  that  adhesive  inflammation  followed  about  four  days 
after  the  application  of  the  ligature,  while  the  time  required  for 
suppuration  to  arise  required  from  one  to  two  days  longer,  conse- 
quently he  determined  the  time  for  the  removal  of  the  ligature  in 
accordance  with  the  general  condition  of  the  patient.  In  young, 
robust  persons  he  removed  the  ligature  on  the  fourth  day,  and  in 
old  or  decrepit  persons  he  allowed  it  to  remain  for  six  days. 

P.  U.  Walther  asserted  that  definitive  closure  of  vessels  after 
ligation  takes  place  within  forty  hours,  and  urged  that  the  ligature 
should  be  removed  after  the  lapse  of  this  time. 

In  Germany  Victor  von  Bruns  was  the  next  and  last  to  bring 
the  temporary  (removable)  ligature   before  the  notice  of  the  profes 


112'  EXPERIMENTAL   SURGERY. 

sion.  He  removed  the  ligature  after  two  or  three  days,  according  to 
the  size  of  the  vessel,  and  supported  his  claims  for  the  superiority  of 
this  method  of  ligation  by  the  results  of  a  large  clinical  experience. 

Pecot  compared  the  methods  of  Jones  and  Scarpa  by  way  of 
experiment  and  came  to  the  conclusion  that  the  round  ligature,  if 
applied  with  sufficient  firmness  to  sever  the  inner  coat  of  the  arteiy, 
excited  adhesive  inflammation  earlier  than  if  the  broad  tape  ligature 
were  used. 

Ponteau  attributed  great  importance  to  the  connective  tissue 
around  blood-vessels  in  the  process  of  obliteration,  hence  he  advised 
that  an  abundance  of  this  tissue  should  be  included  within  the 
ligature. 

Delpech  (1777-1832)  arose  against  Scarpa  in  France,  and  C.  J. 
M.  Langenbeck  in  Germany.  The  latter  regarded  the  adhesion  of 
the  inner  vessel  walls  of  prime  importance  in  effecting  a  permanent 
closure,  while  to  the  thrombus  and  lymph  coagulum  he  assigned  a 
less  important  role.  The  older  German  surgeons  were  in  the  habit 
of  using  hemp  or  linen  ligatures.  The  silk  ligature  was  first  pro- 
posed in  that  country  by  Ph.  Fr.  von  Walther. 

For  the  purpose  of  preventing  the  ill  effects  of  the  customary 
ligature  a  variety  of  ligature  materials  was  proposed,  such  as  chamois 
skin  by  Physik(1814),  catgut  by  Sir  Astley  Cooper,  silkwormgut  by 
Wardrop,  elastic  rubber  strings  by  Levert,  tendons  by  Paul  Eve, 
human  hair  by  Porta.  Metallic  ligatures  were  brought  forward  as 
being  less  irritating  than  the  ordinary  ligature;  gilt  iron  wire  was 
proposed  by  Oilier,  fine  iron  wire  by  B.  von  Langenbeck,  and  silver 
wire  by  Wagner  and  Sims.  Levert  experimented  with  all  kinds  of 
metallic  ligatures,  lead,  gold,  silver  and  platina,  and  always  obtained 
primary  union  of  the  wound.  Metallic  ligatures  were  always  cut 
short  and  remained  permanently  in  the  wound. 

Until  the  end  of  the  eighteenth  century  the  ends  of  the  liga- 
ture were  brought  out  through  the  wound.  The  first  attempts  to 
cut  short  the  ligature  and  leave  it  permanently  in  the  wound  were 
made  by  Lawrence,  who,  in  1814,  published  the  results  of  his  experi- 
ence. For  ligatures  he  used  fine  dentist's  silk.  According  to  Samuel 
Cooper,  however,  the  priority  of  this  procedure  should  belong  to  a 
certain  Haire  of  Essex,  who  is  said  to  have  practiced  it  in  1786. 
Hennen    adopted   the    practice  in   1813,   and  within  four  months 


HISTOLOGY   OF  BLOOD-VESSELS.  113 

employed  it  in  thirty-four  cases  without  observing  any  unfavorable 
results.     Delpech  and  Guthrie  also  indorsed  this  practice. 

The  introduction  of  antiseptic  surgery  has,  however,  wrought 
the  greatest  improvement  in  the  ligature,  and  the  founder  of  anti- 
septic surgery,  Sir  Joseph  Lister,  has  also  furnished  us  with  the  ideal 
ligature — the  aseptic  ligature.  What  has  been  sought  for  centuries 
has  at  last  been  found,  a  ligature  which  will  arrest  the  circulation 
with  safety  and  certainty  and  a  minimum  amount  of  traumatism 
until  the  process  of  cicatrization  is  completed,  and  when  its  work  is 
accomplished,  will  gradually  disappear  by  absorption  and  substitution. 

Since  the  introduction  of  the  antiseptic  treatment  of  wounds 
and  the  aseptic  ligature,  surgery  has  received  a  new  impulse,  results 
have  been  obtained  which  were  never  realized  before,  operations  have 
been  performed  successfully  which  were  previously  beyond  the  grasp 
of  even  the  most  ambitious,  and,  more  than  all,  those  horrible  spec- 
tres, hosjntal  gangrene,  erysipelas,  pyemia,  septicaemia,  and  second- 
ary haemorrhage,  which  haunted  the  surgeons  of  only  fifteen  years 
ago  by  night  and  by  day,  have  almost  completely  disappeared  from 
hospital  as  well  as  private  practice.  For  all  this  we  are  indebted  to 
Lister. 

A  variety  of  other  animal  tissues  have  been  prepared  into  liga- 
tures and  made  aseptic,  and  have  been  recommended  at  different 
times  as  substitutes  for  the  catgut  ligature.  Among  them  we  may 
enumerate  silk,  silkwormgut,  whale  and  deer  tendon,  peritoneum, 
coats  of  blood-vessels,  and  nerve  tissue.  With  the  exception  of  the 
first  two,  all  of  these  ligature  materials,  if  rendered  perfectly  asep- 
tic, will,  after  a  certain  time,  undergo  absorption,  but  it  is  question- 
able if  any  of  them  possess  any  advantage  over  well -prepared  cat- 
gut. Czerny  is  entitled  to  a  great  deal  of  credit  for  the  improved 
silk  ligature.  He  has  demonstrated  that  when  silk  is  made  perfectly 
aseptic  by  boiling  and  immersion  in  carbolized  water,  it  can  be  safely 
left  in  the  tissues,  where  it  becomes  encysted. 

II.    Histology  of  Blood- Vessels. 

For  our  purpose  it  is  not  necessary  to  give  a  complete  descrip- 
tion of  the  minute  anatomy  of  the  blood-vessels,  but  a  brief  allusion 
to  the  arrangement  and  relations  of  the  histological  elements  is 
necessary  in  order  to  study  the  process  of  cicatrization  after  ligation; 


114  EXPERIMENTAL   SURGERY. 

reference  will,  therefore,  be  made  only  to  vessels  of  a  size  requiring 
ligation.  Our  present  knowledge  of  cicatrix  formation  in  blood- 
vessels we  owe  largely  to  a  better  understanding  of  the  structure 
and  functions  of  the  coats  of  the  vessels  on  the  one  hand,  and  to 
laborious  researches  concerning  tissue  regeneration  and  inflammatory 
tissue  formation  on  the  other.  As  arteries  have  been  made  the 
object  of  experiment  more  frequently  than  veins,  we  shall  give  a 
description  of  the  arterial  coats;  and,  with  but  few  unimportant 
exceptions,  all  that  can  be  said  of  the  structure  and  obliterating 
processes  in  arteries  will  apply  with  equal  force  to  veins. 

The  arteries  are  cylindrical  tubes  of  uniform  diameter  between 
their  branches.  The  importance  of  their  function  demands  that 
they  should  occupy  localities  affording  the  greatest  security  against 
injuries  from  without  and  diseased  processes  within  the  body.  In 
man  the  anatomical  protection  against  injury  and  disease  of  the 
arterial  system  exists  in  a  wonderful  degree  of  perfection,  the  vessels, 
as  a  rule,  being  deeply  situated  in  the  concavities,  depressions,  and 
channels  of  bone,  on  the  flexure  side  of  joints,  protected  by  dense 
fascia,  supported  by  muscles,  and,  where  the  location  demands  it, 
surrounded  by  a  soft  cushion  of  adipose  tissue;  as  an  additional 
medium  of  protection  and  source  of  nutrition  they  are  accompanied 
throughout  by  a  sheath  of  connective  tissue,  which  connects  them 
loosely  with  the  surrounding  tissues. 

The  blood-vessels  are  a  product  of  the  mesoblast,  and  are  com- 
posed of  unstriped  muscular  fibres,  elastic  tissue,  connective  tissue, 
and  endothelium.  From  an  anatomical,  physiological,  and,  I  may 
add,  pathological  standpoint,  it  has  been  customary  to  distinguish 
three  coats,  called  respectively,  according  to  their  location:  1.  Inter- 
nal or  Intima;  2.  Middle  or  Media;  3.  External  or  Adventitia.  In 
the  larger  arteries  these  coats  can  be  separated  and  recognized  with- 
out the  aid  of  the  microscope. 

I.     Intima. 

The  intima  is  a  delicate  hyaline  elastic  membrane.  In  the 
larger  arteries  it  is  composed  of  a  single  layer  of  flat  endothelial 
cells,  a  delicate  layer  of  longitudinal  bundles  of  connective  tissue, 
and  a  network  of  elastic  tissue.  His  applied  the  term  endothelium 
to  the  pavement  epithelium  lining  the  inner  walls  of  the  blood-ves- 
sels, lymphatics,  and  serous  cavities,  to  distinguish  it  from  the  other 


HISTOLOGY   OF  BLOOD-VESSELS.  115 

varieties  of  epithelium.  As  found  in  the  vessels,  Auerbach  named 
it  perithelium,  and  Frey  suggested  the  simple  name  of  primary  ves- 
sel tunic.  The  endothelial  layer  is  composed  of  elliptical  or  irregular 
polygonal  cells,  which  are  often  elongated  into  a  lanceolate  shape, 
being  continuous  with  the  endocardium  on  the  proximal,  and  the 
capillary  vessels  on  the  distal  side.  The  shape  of  the  cells  is  greatly 
modified  by  the  degree  of  the  distention  of  the  vessel.  The  nucleus 
is  oval,  its  long  axis,  like  that  of  the  cell,  corresponding  to  the  longi- 
tudinal direction  of  the  vessel. 

In  the  fresh  state  the  contour  of  the  cell  is  very  faint  and 
exceedingly  difficult  to  trace  without  the  assistance  of  staining.  A 
one  per  cent,  solution  of  nitrate  of  silver,  as  first  suggested  by  Von 
Recklinghausen,  stains  the  cement  substance  a  dark  brown,  which 
imparts  a  well-defined  outline  to  the  irregular  margins  of  each  indi- 
vidual cell.  If  the  protoplasm  be  at  the  same  time  stained  with 
chloride  of  gold,  the  picture  is  at  once  rendered  beautiful  and  per- 
fect, illustrating  the  cell  and  its  contents  to  perfection.  The  cement 
substance  surrounding  each  individual  cell  is  a  lifeless  substance, 
closely  allied  to  the  basis  substance  of  the  connective  tissue,  but  it  is 
not  glue-yielding. 

Some  histologists  (Heitzmann,  Strieker,  Klein)  describe  a  net- 
work of  living  matter  within  the  cell  which  sends  delicate  conical 
offshoots  through  the  cement  substance,  thus  forming  a  living  reticu- 
lum, which  connects  the  individual  cells  and  permeates  the  lifeless 
cement  substance  in  every  direction.  These  projections  were  first 
seen  and  described  by  Max  Schultze.  According  to  Heitzmann1 
these  living  prolongations  are  capable  of  producing  new  tissue 
elements.  The  stomata  or  stigmata  in  capillary  vessels  are  slight 
defects  in  the  irregular  outlines  of  the  cement  substance,  and  are 
supposed  to  permit  the  passage  of  the  morphological  elements  of 
the  blood  more  particularly  when  in  a  condition  of  inflammation. 
"  The  attachment  of  endothelia  to  the  subjacent  connective  tissue 
is  either  direct,  by  means  of  delicate  filaments  penetrating  the  rim 
between  the  feet  of  the  endothelia  and  the  neighboring  fibres  of 
connective  tissue;  or  it  is  indirect  by  means  of  an  intervening  base- 
ment layer."" 

1  Microscopical  Morphology  of  the  Animal  Body  in  Health  and  Disease. 
New  York,  1883.    • 

2  Ibid,  page  318. 


116  EXPERIMENTAL   SURGERY. 

The  outer  surface  of  this  basement  membrane  in  many  instances 
is  found  to  be  covered  by  a  layer  of  flat,  polyhedral  cells  discovered 
by  Czerny  by  means  of  silver  staining.  These  cells  may  be  regarded 
as  endothelia.  These  endothelial  or  endothelioid  cells  may  bear 
important  relation  to  the  subject  of  regeneration  of  endothelia. 
Frey1  acknowledges  that  we  are  as  yet  ignorant  concerning  the 
reproduction  of  endothelia,  while  Wendt2  attributes  to  the  vascular 
endothelia  the  still  higher  function  of  being  converted  into  elements 
identical  to  leucocytes  after  separation  by  desquamation.  This 
process  has  been  actually  observed  by  Altmann  in  the  serous 
endothelia  of  the  exposed  mesentery  of  a  frog.3  The  absence  of  a 
direct  blood  supply  does  not  appear  to  deprive  them  of  a  nutritive 
supply  sufficient  for  their  own  nourishment,  which  imparts  to  them 
the  power  of  reproduction  and  which  enables  them  to  assume  an 
active  part  in  various  pathological  processes. 

In  large  arteries  immediately  underneath  the  lining  endothelium, 
there  is  a  special  connective-tissue  membrane  variously  designated 
as  striated  internal  coat  (Kolliker),  innermost  longitudinal  fibrous 
coat  (Remak),  and  internal  fibrous  coat  (Eberth).  In  the  adult  this 
layer  is  distinctly  fibrillated.  Embedded  in  this  membrane  are 
lodged  numerous  branching  corpuscles,  containing  large,  conspicuous 
nuclei  and  so-called  granulation  bodies.  Wendt  regards  the  gran- 
ulation bodies  as  matrix-cells  for  the  regeneration  of  desquamated 
endothelia.  Talma  has  described  similar  bodies,  but  regards  them 
as  the  product  of  endothelia,  instead  of  vice  versa.  This  inner  con- 
nective-tissue membrane  is  prolonged  into  the  smaller  arterial 
branches,  a  single  layer  of  branched  cells  being  interspersed  between 
the  endothelial  lining  and  the  elastic  membrane  of  the  intima.  The 
elastic  membrane  of  the  intima  consists  of  a  network  of  longitudinal 
fibres.  In  the  larger  arteries  this  membrane  is  laminated,  the  lamina 
being  longitudinal   fenestrated  elastic  membranes,  between  which 

pass  longitudinal  networks  of  elastic  fibres. 

i 
2.    Media. 

The  middle  coat  consists  of  unstriped  muscular  fibres,  elastic 

1  Handbuch    der   Histologie   und   Histschemie    des    Menschen.     Leipzig, 
1874,  p.  147. 

2  The  Blood-vessels.     Satterthwaite's  Manual  of  Histology.     N.  Y.  1881. 

3  Archiv  fur  Mikrosk.  Anatomie,  vol.  xvi.  p.  3. 


HISTOLOGY   OF  BLOOD-VESSELS.  117 

and  connective  tissue.  In  vessels  of  small  or  medium  size,  there  is 
a  preponderance  of  muscular  over  elastic  elements,  in  the  larger 
trunks  the  reverse  condition  obtains.  The  muscular  tissue  consists 
of  smooth  nucleated  muscle  fibres  arranged  in  concentric  layers,  and 
disposed  transversely  or  obliquely  around  the  vessel.  Bardeleben 
maintains  that  an  inner  longitudinal  muscular  coat  exists  in  all 
large  and  middle-sized  arteries.  The  muscular  elements  are  arranged 
in  layers  or  groups,  the  interspaces  being  occupied  by  connective 
tissue  and  elastic  fibres  arranged  in  networks.  The  complicated 
relations  of  the  elastic  fibres  in  this  coat  have  caused  no  little  con- 
fusion in  giving  a  description  of  it. 

Henle  describes  four  distinct  layers.  The  middle  coat  is  dis- 
tinctly separated  from  the  intima  by  the  interposition  of  the  internal 
elastic  coat.  The  external  elastic  coat  of  the  media  consists  of  a 
close  network  of  delicate  elastic  fibrils  anastomosing  with  similar 
reticula  from  the  adventitia.  The  third  layer  of  the  elastic  tissue 
fills  the  interspaces  between  the  muscular  layers  in  the  interior  of 
the  middle  coat.  A  small  amount  of  connective  tissue  is  found  in 
this  coat,  usually  accompanying  small  blood-vessels  when  they  per- 
meate it.  The  elastic  fibres  are  usually  arranged  transversely  to 
correspond  with  the  direction  of  the  muscular  fibres,  but  some  of 
them,  especially  those  in  immediate  contact  and  intimately  connected 
with  the  fenestrated  membrane  of  Henle,  are  arranged  in  a  longi- 
tudinal direction.  The  great  degree  of  elasticity  possessed  by  the 
arterial  coats  is,  as  a  rule,  wrongly  attributed  entirely  to  the  existence 
of  the  elastic  tissue;  Hyrtl1  very  properly  remarks  that  all  of  the 
tunics  share  this  property  in  common  with  the  elastic  tissue,  other- 
wise the  remaining  tissues  would  suffer  a  certain  amount  of  distrac- 
tion during  the  expansion  of  the  vessel. 

The  circular  direction  of  the  muscular  fibres,  and  the  same 
direction  of  the  bulk  of  the  elastic  fibres  of  the  middle  coat,  predis- 
pose to  the  laceration  of  this  coat  in  ligating  an  artery  by  means  of 
a  round  ligature  when  firmly  applied;  but,  as  some  of  the  fibres  are 
arranged  obliquely  and  longitudinally,  complete  division  seldom 
occurs,  and  only  on  the  application  of  considerable  force.  The  prin- 
cipal elements  of  this  coat,  in  common  with  the  same  tissues  in  other 
localities,  in  case  of  injury  or  disease  affecting  their  structure,  do  not 

1  Lehrbuch  der  Anatomie  des  Menschen,  Wien,  1878,  p.  140. 


118  EXPERIMENTAL  SURGERY. 

possess  the  power  of  reproduction  or  regeneration.  The  loss  of 
tissue  is  filled  in  by  cicatricial  tissue,  and  solutions  of  continuity  are 
invariably  repaired  by  connective  tissue. 

3.     Adventitia. 

The  external  coat,  the  adstitia  of  Haller,  is  the  simplest  in 
structure,  being  composed  of  interlacing  bundles  of  connective  tissue, 
commingled  with  elastic  lamellae  of  varying  thickness.  The  external 
coat  serves  as  a  nidus  for  the  nutrient  vessels,  the  vasa  vasorum. 
These  vessels  arise  from  the  trunk  which  they  supply  only  in  excep- 
tional cases  (Henle),  but  are  usually  recurrent  vessels  from  the 
nearest  branches.  Hyrtl  has  called  attention  to  the  fact,  that  even 
the  smallest  of  these  vessels  is  accompanied  by  two  veins.  He  has 
never  seen  these  vessels  extend  beyond  the  adventitia.  Frey  asserts 
that  the  media  receives  vessels  from  the  adventitia.  In  the  outer 
coat  the  vessels  resemble  the  capillaries  in  the  connective  tissue,  but 
form  a  more  dense  vascular  network. 

Klein  locates  the  vasa  vasorum  as  follows:  "The  media  and 
adventitia  of  large  vessels  (arteries  and  veins)  contain  a  special  sys- 
tem of  nutrient  blood-vessels,  vasa  vasorum;  the  arterial  and  venous 
branches  of  these  lie  chiefly  in  the  adventitia,  occasionally  also  in  the 
part  of  the  media;  the  capillaries  generally  penetrate  into  the  media 
and  near  the  intima,  only  seldom  also  into  the  latter  (Koster).  In 
the  microscopic  arterial  branches  we  meet  with  capillary  vessels,  as 
a  rule  only  in  the  adventitia."1 

Flint  says:  "  A  tolerably  rich  plexus  of  vessels  is  found  in  the 
external  coats  of  the  arteries.  These  are  called  vasa  vasorum,  and 
come  from  the  adjacent  arterioles,  having  no  direct  connection  with 
the  vessel  on  which  they  are  distributed.  A  few  vessels  penetrate 
the  external  of  the  middle  coat,  but  none  are  ever  found  in  the 
internal  coat."2 

Lymph-spaces  are  present  as  intercommunicating  interfascicular 
spaces,  containing  connective-tissue  cells,  in  all  coats  of  arterial  and 
venous  trunks.  Most  histologists  take  it  for  granted  that  the  ultimate 
distribution  of  nerve  filaments  from  the  cerebrospinal  centres  and 
the  sympathetic,  reach  only  the  adventitia  and  media.     Cohnheim's 

1  Atlas  of  Histology,  Phila.  1880,  p.  143. 

2  The  Physiology  of  Man,  N.  Y.  1866,  vol.  i.,  p.  245. 


HISTOLOGY   OF  BLOOD-VESSELS.  119 

researches,  however,  tend  to  prove  that  the  finest  axis  fibrilli  of  the 
nerves  terminate  in  the  epithelial  layers.  The  termination  was 
described  by  some  observers  as  a  plexus  between  the  epithelia, 
while  others  (Pflueger,  Flemming)  claim  that  the  axis  fibrilli  pene- 
trate the  body  of  the  epithelium  and  may  terminate  in  its  nucleolus. 
Heitzmann  has  traced  the  terminal  filaments  into  the  cement 
substance  between  the  epithelia.  From  the  foregoing  anatomical 
consideration,  it  is  evident  that  the  intima,  although  devoid  of 
blood-vessels,  yet  receives  sufficient  nutritive  supply  to  render  it 
capable  of  regenerating  its  own  elements  in  case  of  loss,  and  of 
assuming  inflammatory  changes  under  the  same  circumstances  and 
in  the  same  manner  as  other  tissues  occupying  the  same  relative 
position  to  the  vascular  system. 

I  will  append  a  short  abstract  of  the  microscopical  description 
of  veins  as  given  by  Raab  as  an  introduction  to  his  paper  "On  the 
development  of  the  cicatrix  in  blood-vessels  after  ligation."  His 
studies  were  made  on  veins  of  dogs.  On  making  a  longitudinal  and 
a  transverse  section  through  a  vein,  the  endothelial  cells  appear  as 
an  exceedingly  delicate  seam  which,  from  the  greater  prominence  of 
the  nuclei  towards  the  lumen  of  the  vessel,  presents  a  slightly  wavy 
appearance.  The  endothelial  cells  are  not  in  direct  contact,  but 
each  is  surrounded  by  a  zone  of  cement  substance  which  fastens  the 
cells  among  themselves  and  to  the  subjacent  tissue.  This  cement 
substance,  according  to  Julius  Arnold,  is  a  remnant  of  the  protoplasm 
from  which  the  original  cells  were  formed.  The  nucleus  containing 
a  number  of  nucleoli  is  located  near  the  centre  of  the  cell.  On  sec- 
tion, *this  nucleus  presents  the  outlines  of  a  half  ellipse,  the  long 
axis  of  which  is  in  contact  with  the  vessel  wall.  The  distance 
between  two  nuclei  of  neighboring  cells  amounts  to  three  or  four 
times  their  longest  diameters,  and  from  this  it  is  easy  to  estimate 
the  area  of  a  protoplasmic  plate. 

As  carmine  stains  only  the  nucleus,  the  contour  of  a  cell  can 
only  be  traced  after  staining  the  specimen  with  nitrate  of  silver. 
The  endothelia  are  either  rhomboidal  or  polygonal  in  shape.  Isolated 
cells  can  be  obtained  in  most  perfect  condition  from  veins  which 
have  been  immersed  for  some  time  in  a  one  per  cent,  solution  of 
chloride  of  sodium,  lime-water,  or  Mueller's  fluid.  For  silver  stain- 
ing, the  valves  are  best  adapted;  they  can  be  spread  on  the  object 
glass  without  any  special  preparation,  and  show  most  beautifully  the 


120  EXPERIMENTAL   SURGERY. 

mosaic  arrangement  of  the  cellular  layer.  On  the  outer  side  of 
the  endothelial  lining  a  framework  of  elastic  tissue  is  found.  The 
strongest  fibres  of  this  network  are  arranged  in  concentric  rows  in 
regular  order,  parallel  with  the  long  axis  of  the  vein,  while  the 
smaller  fibres  take  a  diagonal  or  radiate  course.  In  this  elastic  net- 
work are  found  bundles  of  connective  tissue  crossing  each  other  in 
all  directions.  These  fibres  are  very  dense  immediately  beneath  the 
endothelial  layer,  and  are  intimately  interlaced  with  the  elastic 
tissue;  towards  the  periphery  they  are  more  loosely  arranged. 

The  elastic  membrane,  which  in  the  arteries  completely  sepa- 
rates the  endothelial  from  the  muscular  layer,  does  not  exist  in  the 
veins.  In  transverse  sections  of  a  vein,  the  longitudinal  elastic 
fibres  appear  as  light,  round,  or  oval  objects  between  the  loose  wavy 
connective-tissue  bundles,  and  in  the  spaces  surrounding  them  an 
occasional  spindle  or  stellate  cell  with  a  large  nucleus  may  be  seen. 
Muscular  tissue  is  not  to  be  found  in  the  superficial  cutaneous  veins 
of  dogs.  It  is  also  absent  in  the  internal  jugular  and  femoral  veins. 
The  adventitia  consists  of  loose  connective-tissue  and  firm  elastic 
fibres,  separated  by  a  distinct  space  from  the  middle  coat. 

III.    Intermediate  Ligature,  Ligature  en  masse. 

All  of  the  older  surgeons  were  in  fear  of  a  too  early  separation 
of  the  ligature,  and  aimed  to  prevent  secondary  haemorrhage  as  the 
result  of  such  an  occurrence  by  including  adjacent  tissues,  thus  pro- 
tecting the  vessel  against  undue  pressure.  The  object  of  this 
practice  was  simply  to  apply  the  ligature  as  a  provisional  mechanical 
agent  to  arrest  the  flow  of  blood  in  a  vessel,  without  any  theory*  as  to 
the  permanent  closure  of  the  vessel.  The  ligature  was  passed 
underneath,  with  points  of  entrance  and  exit  some  distance  from  the 
vessel,  and  firmly  tied.  This  method  was  practiced  by  Pare\  and 
through  his  influence  and  example  it  was  adopted  by  all  of  the 
prominent  surgeons  until  nearly  the  end  of  the  eighteenth  century. 
Guillemeau,  Thevenin,  Garengeot,  LeDran,  Louis,  Dionis,  and  Petit 
were  faithful  followers  of  Par 6,  and  with  few  unimportant  modifica- 
tions, followed  his  directions  to  the  letter.  Since  the  definitive 
closure  of  vessels  has  been  made  an  object  of  study  and  experiment, 
this  method  of  ligation  has  been  abandoned  and  is  only  resorted  to 
in  exceptional  cases  where  isolation  of  the  vessel  or  vessels  is  impos- 
sible from  the  nature  or  location  of  the  wound. 


IMMEDIATE   OR   DIRECT  LIGATURE.  121 

IV.    Immediate  or  Direct  Ligature. 

The  experiments  of  Jones  led  the  way  to  the  immediate  or 
direct  ligature.  Jones  and  his  followers  placed  great  stress  on  the 
laceration  of  the  inner  tissues  of  an  artery  by  the  circular  constric- 
tion of  the  ligature,  in  effecting  provisional  and  definitive  closure  of 
the  lumen  of  the  vessel.  The  simple  round  ligature  was  gradually 
adopted  by  all  surgeons  who  aimed  at  division  of  the  internal  coats 
by  the  ligature.  The  size  of  the  ligature  has  also  undergone 
considerable  modification.  Bell  used  fine  oiled  ligatures  which  he 
supposed  would  apply  themselves  accurately  to  the  artery.  Some 
united  from  two  to  as  many  as  eight  (Arndt)  ligatures  into  one 
string. 

Lisfranc  used  moderately  broad  ligatures,  but  he  claimed  that 
in  tying  the  knot  they  were  changed  into  round  cords  and  would  as 
effectually  divide  the  inner  coats  as  the  round  ligature.  Velpeau 
used  ligatures  proportionate  in  size  to  the  vessel  to  be  ligated. 
Hodgson  used  the  fine  round  ligature.  Lawrence  spoke  highly  of 
the  use  of  very  fine  silk,  dentist's  silk,  in  tying  arteries  of  any  size. 
A.  Cooper  was  also  in  favor  of  the  round  single  ligature.  The  cir- 
cular constriction  of  Jones,  with  a  single  round  thread,  by  degrees 
won  the  favor  of  surgeons  and  firmly  maintained  its  position  as 
the  best  method  of  ligation  until  the  advent  of  the  aseptic  ligature. 
The  advantages  presented  by  this  method  during  its  pre-antiseptic 
period  were:  1.  Effective  and  safe  provisional  closure  of  vessel. 
2.  Promotion  of  process  of  definitive  closure  of  vessel.  3.  The 
spontaneous  elimination  of  the  ligature  by  diminishing  the  amount 
of  tissue  included  in  the  loop  of  the  ligature. 

X.    Scarpa's  Aplatissement. 

Scarpa's  ligature  was  intended  by  its  author  to  fulfill  the  two 
essential  indications  in  obliterating  the  lumen  of  a  vessel:  1.  To 
arrest  the  circulation  temporarily  by  mechanical  pressure  without 
lacerating  the  tissues  of  the  vessel.  2.  To  approximate  and  keep 
in  constant  and  accurate  contact  a  sufficiently  large  surface  of  the 
inner  vessel  walls  for  the  union  to  take  place  by  adhesion.  His  lead- 
ing idea  was  that  the  intima  resembled  serous  surfaces,  and  only  a 
moderate  amount  of  irritation  was  necessary  for  rapid  union  to  take 
place,  and  that  the  injury  inflicted  by  the  circular  ligature  was  too 


122  EXPERIMENTAL   SURGERY. 

severe  to  obtain  the  most  desirable  result.  He  used  ligatures  two 
lines  in  width  and  tied  over  a  small  cylinder  of  linen.  The  ligature 
was  usually  expelled  spontaneously  about  the  fifteenth  day,  but  if 
this  was  not  the  case  and  it  was  loose  upon  the  vessel,  it  should  be 
removed  at  this  time.  Scarpa's  theories  found  many  admirers,  who 
introduced  modifications  in  the  operation  to  suit  their  individual 
ideas.  Forster  substituted  for  the  cylinder  of  linen,  charpie  and 
cork;  Deschamps,  agaricus;  Desault,  small  plates  of  wood;  Cline, 
cork;  and  Roux,  small  rolls  of  diachylon  plaster. 

In  England  this  practice  was  advocated  by  Crampton,  and  in 
France  it  was  represented  more  particularly  by  Boyer  and  Roux. 
Some  exponents  of  the  theory  of  aplatissement,  while  believing  in 
the  doctrine,  objected  to  the  introduction  of  foreign  bodies  into  the 
wound,  which  they  regarded  not  only  as  useless  but  injurious  to 
the  healing  of  the  wound.  Jameson  used  ligatures  made  of  strips  of 
raw  chamois  skin,  which  he  claimed  would  by  their  pliability  and 
elasticity  hold  in  approximation  the  inner  vessel  walls  without  inflict- 
ing injury  to  its  tissues.  Without  means  to  prevent  suppuration,  it 
can  be  readily  understood  that  the  expectations  held  by  the  origi- 
nator of  this  method  of  ligation  and  his  followers  were  not  realized, 
and  it  was  by  degrees  displaced  by  the  round  ligature. 

VI.     Double  Ligature. 

The  double  ligature  is  mentioned  by  Celsus  and  iEtius. 
Rolandus  of  Parma  speaks  of  the  double  ligature  as  applied  to  the 
vena  organica  (jugularis).  John  Bell  and  Maunoir  not  infrequently 
applied  two  ligatures  in  close  proximity.  In  ligating  arteries  in 
their  continuity,  Abernethy  always  applied  the  double  ligature  after 
isolating  the  vessel  freely,  claiming  that  even  if  the  intermediary 
isolated  portion  sloughs  the  ligatures  will  successfully  guard  against 
secondary  haemorrhage.  As  an  important  advantage  of  this  method 
he  mentions  that  the  vessel  can  be  divided  between  the  ligatures,  which 
relieves  tension  and  allows  both  ends  of  the  artery  to  retract  into 
the  tissues — occupying  then  the  same  favorable  position  as  vessels 
divided  during  an  amputation.  The  double  ligature  has  been  fre- 
quently employed  in  experiments  for  the  purpose  of  studying  the 
process  of  cicatrization  in  blood-vessels  after  ligature,  and  will  be 
again  referred  to  in  that  connection. 

According  to  time,  ligatures  maybe  classified  into:     1.  Momen- 


MOMENTARY  LIGATURE.  123 

tary:  2.  Temporary;  3.  Permanent.  The  first  two  varieties  aim  at 
obliteration  of  the  lumen  without  loss  of  continuity  of  the  vessel, 
while  until  recently  the  permanent  ligature  was  always  expected  to 
divide  the  artery  before  it  could  be  eliminated  as  a  foreign  body  from 
the  wound. 

YII.    Momentary  Ligature. 

A  series  of  experiments  on  animals  made  by  Jones  satisfied  him 
that  definitive  closure  of  an  artery  frequently  takes  place  by  draw- 
ing the  ligature  tightly  and  removing  it  at  once.  The  rupture  of 
the  internal  coats  in  many  instances  produced  satisfactory  closure  by 
mechanically  interfering  with  the  circulation,  and  causing  the  forma- 
tion of  a  thrombus,  the  definitive  obliteration  following  as  the  natural 
consequence  of  the  traumatism.  To  insure  these  results  more  con- 
stantly, he  made  several  of  these  circular  constrictions  in  close  prox- 
imity, so  as  to  inflict  a  greater  amount  of  traumatism,  and  prociire  a 
larger  surface  for  cicatrization.  Jones  called  attention  to  the  superior 
'  advantages  offered  by  this  method  of  ligation  over  all  other  methods, 
as  it  would  secure  obliteration  of  vessels  without  incurring  the 
necessity  of  leaving  a  foreign  substance  in  the  wound.  Unfortu- 
nately, however,  the  results  obtained  were  so  uncertain  that  he  did 
not  dare  to  recommend  its  adoption  in  practice.  In  many  instances, 
as  late  as  the  third  or  fourth  day,  the  artery  was  found  permeable,  a 
sufficient  proof  that  the  operation  with  all  its  other  advantages  lacked 
reliability. 

Porta  made  fifty  experiments  with  the  momentary  ligature  on 
dogs,  sheep,  and  goats,  with  the  result  that  partial  or  complete  oblit- 
eration of  the  vessel  by  thrombus  or  lymph-coagulum  followed  in  only 
ten,  while  in  all  of  the  remaining  cases,  only  division  of  the  inner 
coats  could  be  demonstrated. 

Maunoir  attempted  to  accomplish  the  same  object  by  different 
means.  He  crushed  the  internal  coats  of  arteries  with  a  forceps  of 
his  own  construction,  and  expected  the  same  series  of  changes  to 
occur  in  their  interior  as  the  result  of  the  laceration  of  tissue,  but 
his  results  must  have  been  equally  unsatisfactory,  as  the  procedure 
does  not  appear  to  have  been  adopted  to  any  extent  in  practice. 

VIII.     Temporary  Ligature. 

The  temporary  ligature  was  introduced  for  the  purpose  of  obvi- 
ating the  deleterious  effects  of  the  presence  of  a  foreign  body  in  the 


124  EXPERIMENTAL   SURGERY. 

healing  of  a  wound,  and  the  process  of  cicatrization  in  the  blood- 
vessel. While  the  ordinary  ligature  remained  for  a  period  of  time 
varying  from  three  to  twenty  days,  it  has  been  argued  that  the  aver- 
age time  necessary  for  the  ligature  to  remain  is  much  less;  hence 
various  contrivances  were  invented  which  were  intended  as  substi- 
tutes for  the  ligature,  and  which  could  be  removed  with  greater 
facility  after  the  necessary  time  had  elapsed;  such  were  the  pressure 
forceps  designed  by  Deschamps,  Desault,  Percy,  Assolini,  Kcehler, 
Porter,  Billroth,  L' Estrange,  Richardson,  Crampton,  Nunnelly, 
Wolfe,  Jeoffresson,  and  Speir.  A  similar  function  and  sphere  was 
assigned  to  the  percutaneous  acupressure  of  Middeldorpf,  the  ansa 
fill  metallici  of  B.  v.  Langenbeck,  the  filo-pressure  of  Dix,  the  ansa 
ha5mostatica  a  tergo  of  Schmitz,  and  more  recently  the  removable 
ligature  of  V.  v.  Bruns. 

The  laborious  researches  of  Jones  prepared  the  way  for  the 
temporary  ligature.  Travers  believed  with  Jones  that  vessels  are 
obliterated  by  inflammatory  adhesive  exudation  and  union  between  ■ 
the  inner  coats,  but  affirmed  that  the  inflammatory  process  requires 
a  longer  period  of  time  to  secure  the  requisite  firmness  in  the  adhe- 
sions. His  first  experiments  were  directed  towards  ascertaining  the 
length  of  time  required  for  a  sufficiently  firm  adhesion  to  take  place. 
The  experiments  were  made  on  the  carotid  of  horses  and  asses.  The 
ligature  was  applied  either  in  the  form  of  a  loop,  or  tied  over  a  tape 
placed  parallel  with  the  artery  for  the  purpose  of  facilitating  its 
removal.  The  ligature  was  removed  after  one,  two,  and  six  hours, 
and  the  animal  killed  from  twenty  to  thirty  hours  after  the  operation. 
In  fifty  per  cent,  of  the  cases,  where  the  ligature  remained  for  one 
hour,  the  vessel  was  not  obliterated.  In  all  cases  where  it  was 
allowed  to  remain  from  two  to  six  hours,  the  experiment  proved 
successful.  From  these  experiments  he  concluded  that  six  hours  is 
the  longest  time  required  for  the  ligature  to  remain,  and  that  at  this 
time  definitive  occlusion  has  always  been  accomplished. 

In  order  to  determine  whether  the  closure  of  the  vessel  is  per- 
fect at  this  time,  or  whether  it  is  effected  after  the  removal  of  the 
ligature,  he  made  another  series  of  experiments,  dividing  the  artery 
on  the  peripheral  side  after  removing  the  ligature.  These  experi- 
ments satisfied  him  that  definitive  closure  takes  place  after  the 
removal  of  the  ligature,  and  is  effected  by  an  exudation  of  plastic 
lymph.     If  the  ligature  remained  for  twelve  hours,  and  the  artery 


TEMPORARY  LIGATURE.  125 

was  cut  on  the  peripheral  side,  no  haemorrhage  followed  its  removal. 
He  reduced  his  theory  to  practice  by  ligating  the  brachial  artery  in 
a  man  suffering  from  aneurism,  and  removed  the  ligature  fifty  hours 
after  the  operation.  No  haemorrhage  followed,  and  the  patient 
recovered.  He  next  tied  the  femoral  artery  for  popliteal  aneurism, 
and  removed  the  ligature  twenty-seven  hours  later.  Pulsation  soon 
returned  below  the  seat  of  operation.  The  disappointment  due  to 
the  failure  in  this  case  deterred  him  from  giving  the  temporary 
ligature  further  trial,  and  he  returned  to  the  ordinary  ligature. 
This  method  was  tested  by  a  few  English  surgeons,  but,  not  meeting 
with  more  encouraging  results,  was  soon  completely  abandoned. 
Scarpa,  in  Italy,  was  the  next  advocate  of  temporary  ligature.  His 
pathological  views  regarding  the  use  of  the  ligature  and  the  process 
of  obliteration  of  vessels,  as  well  as  his  method  of  ligation,  are  given 
elsewhere. 

Delpech  claimed  that  a  few  days  after  ligation,  the  ligature  is 
found  loose  on  the  vessel,  and  consequently  can  exert  no  influence 
for  good,  and  therefore  should  be  removed  like  any  other  foreign 
body,  so  as  not  to  interfere  with  the  normal  healing  of  the  wound. 

Velpeau  also  regarded  the  temporary  ligature  with  favor.  P. 
U.  Walther  studied  the  effects  of  the  temporary  ligature  on  animals. 
With  a  ligature  instrument  of  his  own  device,  he  aimed  to  divide 
the  inner  coats  of  the  vessel,  and  removed  the  ligature  after  forty- 
eight  to  seventy- two  hours,  when  definitive  closure  was  always  found 
perfect. 

N.  R.  Smith  constricted  the  vessels  with  an  iron  wire  passed 
through  a  silver  tube,  and  found  arteries  of  the  fourth  and  fifth  size 
obliterated  after  six  hours.  The  femoral  artery  was  found  perma- 
nently closed  after  two  days.  Victor  v.  Bruns  originated  his  method 
of  filo-pressure  in  1868. '  The  silk  ligature  which  he  used  was 
passed  around  the  artery  and  brought  out  of  the  wound  through  a 
silver  cannula  with  a  crossbar,  to  which  it  was  fastened.  Arteries  of 
the  size  of  the  radial  he  found  closed  after  eighteen  hours,  while 
larger  arteries  required  from  one  to  three  days.  For  six  years  this 
method  was  used  exclusively  in  all  cases  requiring  ligation  in  Bruns' 
clinic,  with  entire  satisfaction.      Only  in  two  cases  did  secondary 

1  Paul  Bruns,  Die   temporare  Ligatur  der  Arterien,  Deutsche  Zeitsehr.  f. 
Chir.,  B.  V..  S.  827. 


126  EXPERIMENTAL  SURGERY. 

haemorrhage  occur;  in  one  instance  the  common  carotid  was  heated 
during  an  operation  for  the  removal  of  a  cancerous  tumor  of  the 
thyroid  gland,  and  the  ligature  removed  on  the  fifth  day;  in  the 
second  case  the  femoral  was  ligated,  and  the  ligature  removed  on 
the  third  day. 

The  great  objections  against  the  temporary  ligature  have  always 
been,  that  the  wound  could  not  be  completely  closed,  or  had  to  be 
reopened  at  the  time  of  removal  of  the  ligature,  thus  increasing  the 
risks  of  suppuration,  and  preventing  primary  union  of  the  wound, 
circumstances  which  the  ligature  was  intended  to  obviate.  Absence 
of  suppuration  and  primary  union  of  the  wound  are  the  most  reliable 
safeguards  against  secondary  hemorrhage  after  any  method  of 
ligation,  and  any  method  which  cannot  secure  these  results  with 
some  degree  of  certainty,  must  be  considered  as  faulty  in  principle 
and  practice.  This  can  be  said  without  hesitation  against  the  tem- 
porary ligature  as  described  above.  The  aseptic  animal  ligature 
must  be  considered  as  a  temporary  ligature  in  every  sense  of  the 
word,  but  the  material  of  which  it  is  composed  is  removed  by  healthy 
active  granulations  instead  of  by  the  hand  of  the  surgeon,  an 
advantage  which  it  would  be  difficult  to  over-estimate,  and  which 
neutralizes  all  valid  objections  against  the  temporary  ligature.  The 
ligature  of  the  future,  then,  will  be  the  aseptic  animal  ligature. 

IX.    Permanent  Ligature. 

The  permanent  ligature  is  composed  of  a  material  which  will 
remain  for  the  most  part  unchanged  in  the  tissues  of  the  body,  and 
is  either  permanently  retained  (encysted)  or  spontaneously  expelled. 
Before  the  aseptic  ligature  came  into  use,  the  ligature  usually  cut 
its  way  through  the  remaining  tissues  of  the  artery  in  from  three  to 
twenty  days,  by  a  process  of  molecular  death,  and  was  spontaneously 
expelled,  thus  destroying  the  continuity  of  the  vessel  in  every 
instance. 

Hodgson  held  that  the  ligature  as  usually  applied,  divides  the 
two  inner  coats  of  the  vessel,  and  destroys  the  vitality  of  the  circular 
constricted  portion  of  the  adventitia,  which  separates  like  any  other 
slough  and  comes  away  in  the  loop  of  the  ligature.  The  same 
explanation  is  given  by  Guthrie,  Brodie,  and  Gross.  Bruns,  how- 
ever, maintains  that  the  constricted  portion  under  the  pressure  of 
the  ligature  undergoes  molecular  necrosis,    a   process   necessarily 


PERMANENT  LIGATURE.  12*3 

attended  by  suppuration.  He  also  claims  that  in  animals,  if  the 
ligature  is  cut  short,  it  cuts  through  the  tissues  and  is  encysted  in 
the  cicatrix. 

Porta  studied  experimentally  the  future  fate  of  ligatures  in  the 
wound.  He  made  three  hundred  experiments,  using  catgut,  silk, 
hemp,  linen,  and  horse-hair  ligatures,  cutting  them  short.  The 
animals  were  killed  from  a  few  days  to  three  years  after  the  opera- 
tion. Of  the  three  hundred  ligatures,  sixty-four  were  completely 
absorbed;  of  eighty  catgut,  thirty-three;  of  one  hundred  and  twenty 
silk,  nineteen;  of  fifty  linen,  ten;  of  forty  horse-hair,  two.  Of  the 
two  hundred  and  thirty-six  ligatures  which  remained  in  the  wound, 
only  twenty-six  were  found  lodged  in  abscess  cavities.  He  claimed 
that  the  ligature  destroyed  the  continuity  of  the  vessel  by  intersti- 
tial absorption. 

P.  U.  Walther  in  his  numerous  experiments  with  the  temporary 
ligature  found  the  adventitia  divided  in  only  one  case.  He  removed 
the  ligatures  at  variable  periods  of  time,  from  one  hour  to  one  hundred 
and  ten  hours  after  operation.  P.  Brans '  made  fifteen  experiments 
to  determine  the  effect  of  the  ligature  on  the  coats  of  vessels,  and 
confirmed  the  observations  of  Walther. 

If  the  constricted  portion  of  an  artery  is  examined  some  time 
after  the  application  of  the  ligature,  it  is  not  always  easy  to  deter- 
mine whether  complete  division  has  taken  place  or  not.  A  few  days 
after  ligation,  the  artery  in  close  proximity  to  the  ligature  is  thick- 
ened, the  swelling  on  each  side  effacing  the  depression  made  by  the 
ligature,  and  shutting  the  ligature  out  of  sight.  The  traumatic 
peri-arteritis  produces  a  connective  tissiie  proliferation  which  covers 
the  ligature  and  both  ends  of  the  artery  as  the  provisional  callus 
after  fracture  surrounds  the  broken  ends  of  the  bone.  If  the  inflam- 
mation does  not  proceed  beyond  the  process  of  tissue  formation,  the 
granulation  tissue  is  converted  into  cicatricial  tissue,  which  forms  an 
additional  connecting  medium  between  the  ends  of  the  artery,  and 
by  forming  at  the  same  time  a  capsule  around  the  ligature,  the 
latter  becomes  permanently  encysted. 

If  the  end  of  an  artery  is  tied,  the  vitality  of  the  ligated  stump 
will  depend  on  the  manner  in  which  the  wound  heals;  if  suppura- 
tion takes  place  it  will  in  all  probability  separate  as  a  slough,  and 

1  Op.  cit. 


128  EXPERIMENTAL   SURGERY. 

with  the  ligature  will  escape  with  the  wound  secretions;  if,  on  the 
other  hand,  the  wound  heals  by  primary  union,  it  will  either  remain 
in  organic  connection  with  the  vessel  and  form  new  vascular  com- 
munications with  the  adjacent  tissue,  or  in  the  event  of  a  cutting 
through  of  the  ligature,  it  may  still  retain  its  vitality  and  remain  in 
the  tissues,  or  finally  it  may  be  removed  by  gradual  absorption. 
John  Bell  and  Otto  Weber  were  convinced  that  the  end  of  the  ligated 
vessel  invariably  separates  and  dies.  There  is,  however,  good 
reason  to  believe  that  the  ligated  artery  stump  in  the  absence  of 
suppuration  will  retain  its  vitality,  and  will  again  unite  with  the 
surrounding  tissues  from  which  it  receives  its  nutrition.  P.  Bruns 
made  a  few  experiments  in  this  direction. 

Experiment  1.  Double  ligation  of  carotid  artery  of  a  dog;  division  of 
artery  between  ligatures.  The  animal  was  killed,  and  parts  were  examined 
fourteen  days  after  operation.  The  ends  of  the  artery  were  separated  2  cm., 
the  interspace  was  bridged  over  by  a  band  of  connective  tissue  in  which  were 
embedded  both  ligated  stumps  a  short  distance  from  the  closed  ends  of  the 
artery. 

Experiment  2.  Vessels  and  operation  the  same.  The  separated  ends  of 
the  artery  were  embedded  in  the  intermediate  connective-tissue  string. 

Experiment  3.  Femoral  artery,  operation  the  same.  Local  conditions 
the  same,  only  that  the  bridge  of  new  connective  tissue  was  larger  and  firmer. 
The  separated  ends  of  the  artery  were  somewhat  reduced  in  size. 

Experiment  4.  Femoral  artery,  operation  the  same.  Separated  pieces 
were  much  smaller,  and  incorporated  in  the  newly  formed  connective  tissues. 

In  all  of  these  experiments  it  appears  that  the  ligature  cut  its 
way  through  the  tissues  of  the  artery,  thus  completely  separating 
the  ligated  stumps,  and  still  they  retained  their  vitality  through 
the  influence  of  the  surrounding  living  tissue.  The  ligatures  were 
undoubtedly  drawn  very  tight,  and  as  the  operations  were  done 
without  antiseptic  precautions,  the  reaction  was  in  excess  of  what 
was  necessary  to  obtain  obliteration  of  the  vessels.  These  circum- 
stances will  go  far  towards  furnishing  an  explanation  of  the  uniform- 
ity with  which  the  constricted  portion  of  the  vessel  gave  way  under 
the  ligature. 

The  use  of  the  aseptic  ligature  and  antiseptic  treatment  of  the 
wound  tend  to  preserve  the  continuity  of  the  ligated  vessel,  as  has 
been  abundantly  proved  by  clinical  experience  and  experimental 
research.  In  many  of  my  specimens  it  can  be  seen  that  weeks  and 
months  after  the  operation  the  ligatures  remained  in  their  original 


ASEPTIC   LIGATURE.  129 

location  and  occupied  the  same  relative  position  to  the  vessel  as 
immediately  after  the  operation,  the  ligature  in  every  instance  where 
suppuration  was  prevented  being  surrounded  or  encapsuled  by  a 
dense  capsule  of  connective  tissue.  If  the  end  of  an  artery  is  ligated 
under  antiseptic  precautions,  the  stump  of  the  artery  retains  its 
vitality  in  a  similar  way,  and  is  nourished  in  the  same  manner  as  the 
pedicle  after  ovariotomy,  the  only  difference  being  that  in  the  former 
instance  the  local  conditions  are  perhaps  more  favorable  for  the 
preservation  of  the  vitality  of  the  ligated  parts. 

X.    Aseptic  Ligature. 

In  his  first  communication  to  the  profession  on  this  subject 
Lister  alludes  to  the  advantages  of  the  aseptic  ligature  as  follows: 
"If  the  antiseptic  ligature  be  employed  it  merely  inflicts  a  wound 
or  injury  upon  the  vessel,  without  introducing  any  permanent  cause 
of  irritation.  The  injured  part,  therefore,  becomes  repaired  after 
the  manner  of  a  subcutaneous  wound  without  passing  through  the 
process  of  granulation  and  suppuration,  which  is  induced  by  the 
employment  of  the  ordinary  septic  ligature."1 

It  may  now  be  truly  said  that  some  form  of  aseptic  ligature  is 
used  at  present  by  almost  every  surgeon,  and  that,  while  the  merits 
of  the  antiseptic  treatment  of  wounds  are  still  denied  by  many,  few 
or  none  would  use  the  ordinary  ligature  without  realizing  that  their 
duty  towards  their  patients  had  not  been  conscientiously  discharged. 
Perhaps  no  other  surgical  procedure  has  ever  enjoyed  the  confidence 
of  the  whole  profession  throughout  the  civilized  world  to  the  same 
extent  as  the  aseptic  ligature.  This  universal  faith  in  the  reliability 
and  safety  of  the  aseptic  ligature  is  only  a  natural  outgrowth  of  the 
superior  results  following  its  use.  Protracted  suppuration  in  wounds 
the  result  of  retained  ligatures,  secondary  haemorrhage,  and  suppura- 
tive inflammation  of  vessels  have  been  gradually  diminishing  in 
frequency,  and  bid  fair  under  the  influence  of  the  aseptic  ligature 
to  be  almost  completely  expunged  from  the  future  category  of 
wound  complications. 

Nussbaum  very  appropriately  remarks:  "Catgut  is  withont 
doubt  Lister's  greatest  discovery."2     And  again:  "How  pleasant  it 


1  The  Lancet,  April  8,  1869. 

2  Leitfaden  zur  antiseptischen  Wund-behandlung.      Stuttgart,  187!),  S.  23. 

8 


130  EXPERIMENTAL   SURGERY. 

is  to  cut  the  ligatures  short  and  leave  them  unconcerned  to  their  fate 
in  the  wound!  In  ovariotomies,  etc.,  their  value  cannot  be  over- 
estimated. The  manner  in  which  catgut  adheres  to  an  artery,  form- 
ing connections  with  it  and  the  surrounding  tissues,  assisting  at  the 
same  time  in  forming  a  firm  ring  around  the  coats  of  the  artery,  are 
exceedingly  welcome  occurrences,  guarding  against  secondary 
arterial  haemorrhage  in  ligating  in  the  continuity  of  a  vessel,  and 
rendering  even  the  application  of  a  ligature  in  close  proximity  to  a 
large  collateral  branch  devoid  of  danger.     All  this  silk  cannot  do." 

Before  the  introduction  of  antiseptic  surgery  suppuration  at  the 
seat  of  ligature  was  almost  a  necessity.  As  suppuration  interfered 
seriously  with  the  hyperplastic  processes  in  the  tissues  of  the  arterial 
tunics,  secondary  haemorrhage  was  of  frequent  occurrence,  because 
the  adhesion  between  the  surfaces  of  the  interior  walls  of  the  vessel 
were  not  sufficiently  firm  to  resist  the  intra-arterial  pressure  at  the 
time  of  the  separation  of  the  ligature.  It  was  on  this  account 
deemed  necessary  by  the  older  surgeons  in  deligating  an  artery  in 
its  continuity,  to  apply  the  ligature  at  least  an  inch  distant  from  the 
next  collateral  branch,  so  as  to  favor  the  formation  of  a  thrombus. 
The  aseptic  ligature  marks  a  new  era  in  the  surgery  of  blood-vessels. 
Ligating  a  vessel  under  antiseptic  precautions  presents  the  following 
advantages : 

1.  The  ligature  remains  undisturbed  in  the  wound,  becoming 
either  absorbed  or  encysted  after  having  fulfilled  the  purpose  of  a 
provisional  haemostatic. 

2.  Prompt  obliteration  of  the  vessel  takes  place  by  prolifera- 
tion of  new  tissue  elements  from  pre-existing  cells  independently  of 
the  formation  of  a  thrombus;  in  fact,  thrombosis  is  often  wanting. 
The  constricted  portion  of  the  vessel  does  not  necrose,  it  is  infiltrated 
like  the  catgut  with  living  tissue.1  Bardeleben  makes  a  similar 
assertion.2 

In  all  operations  with  the  aseptic  ligature  the  small  size  of  the 
clot  and  its  frequent  entire  absence  is  in  remarkable  contrast  with 
the  results  observed  after  the  ordinary  septic  ligature.  The  impor- 
tance of  the  thrombus  as  an  active  agent  in  the  definitive  closure  of 
vessels  has  vanished  before  the  brilliant  results  obtained  with  the 

1  C.  Hueter,  Grundriss  der  Chirurgie,  1880,  B.  I.  p.  146. 

2  Berl.  klin.  Wochenschrif  t,  No.  29,  1875. 


ASEPTIC  LIGATURE.  131 

aseptic  ligature.  John  A.  Liddel,  in  speaking  of  vein  ligature,  says: 
"  If  a  ligature  of  animal  origin,  such  as  carbolized  catgut,  has  been 
applied  the  approximated  walls  grow  directly  together,  and  the 
ligature  itself  disappears  by  absorption  or  is  replaced  by  new  con- 
nective tissue."  x 

A  discrepancy  of  opinion  still  exists  regarding  the  time  in  which 
the  catgut  ligature  is  absorbed.  The  results  of  experiments  in  this 
direction  have  not  been  uniform.  Lister  ligated  the  carotid  artery 
of  a  calf  with  carbolized  catgut,  and  on  examining  the  parts,  thirty 
days  after  operation,  he  found  only  small  portions  of  the  ligature 
remaining,  the  rest  having  been  absorbed  and  its  space  occupied  by 
new  tissue. 

Czerny  operated  on  rabbets,  and  examined  the  parts  from  one 
to  thirty  days  after  operation.  After  a  number  of  days  the  ligature 
was  always  found  loose  on  the  vessel,  softened  and  infiltrated  with 
cells.  Fillenbaum  applied  a  double  ligature  to  the  carotid  artery  of 
a  dog,  and  killing  the  animal  fourteen  days  subsequently,  found  only 
microscopical  remnants  of  the  ligatures.  Schurhardt  experimented 
with  guinea  pigs,  and  if  the  ligature  was  allowed  to  remain  for  five 
weeks,  only  traces  of  it  remained. 

P.  Brans2  operated  on  dogs  four  times,  tying  the  femoral  and 
axillary  arteries,  no  antiseptic  precautions  being  used,  and  the 
specimens  were  examined  after  ten  days.  In  two  cases  the  catgut 
ligatures  had  undergone  but  little  change;  in  the  third  case  the 
ligature  could  not  be  detected  with  the  naked  eye,  but  the  micro- 
scope showed  traces  of  it;  in  the  fourth  case  a  double  ligature  had 
been  applied  to  the  femoral  artery  4  cm.  apart,  and  in  this  instance 
the  proximal  ligature  showed  no  change,  while  of  the  distal  ligature 
only  the  knot  remained.  He  also  ligated  the  carotid  artery  three 
times -and  examined  specimens  after  twenty  days  had  elapsed,  and 
found  in  only  one  instance  traces  of  the  ligature  on  making  longitu- 
dinal section  of  the  vessel.  In  two  cases  he  examined  the  ligatures 
after  thirty  days,  the  carotid  and  axillary  arteries  being  the  vessels 
tied,  and  found  only  microscopical  traces.  In  four  more  operations 
he  tied  the  axillary  and  femoral  arteries,  and  examined  after  forty 
days,  and  on  careful  examination  found  traces  of  the  ligature  only 

1  Injuries  of  Blood-vessels.    The  Internat.  Encycl.  of  Surg.,  vol.  iii.  p.  211. 

2  Die  temporare  Ligatur  der  Arterien,  Deutsche  Zeitschr.  f.  Chirurgie,  B.V. 


132  EXPERIMENTAL   SURGERY. 

in  one  case,  while  in  the  remaining  three  the  microscope  revealed 
only  traces.  From  these  experiments  he  concluded  that  the  catgut 
ligature  from  the  first  to  the  tenth  day  is  either  not  changed  at  all, 
or  that  the  changes  are  not  constant;  absorption  is  constant  from  the 
twentieth  to  the  thirtieth  day,  and  after  the  fortieth  day  only  micro- 
scopical remnants  can  be  found. 

M.  Arnaud,  in  a  series  of  careful  experiments,  gives  these  results 
in  regard  to  the  absorption  of  carbolized  catgut  ligatures : 1 

Catgut  disappeared  once  in         - 

"  "  twice  in 

"  "  once  in         - 

Catgut  distinctly  visible  once  in       - 


4 

days 

7 

u 

9 

u 

4 

u 

9 

" 

11 

u 

it; 

U 

Catgut  visible  but  softened  and  infiltrated  once  in 

The  time  required  for  absorption,  although  variable  in  the  same 
animals  and  in  the  same  locality,  will  depend  on:  1.  The  quality  of 
the  ligature;  2.  The  size  of  the  ligature;  3.  The  nature  of  the 
tissue  with  which  it  is  kept  in  contact;  4.  The  presence  or  absence  of 
suppuration.  P.  Bruns  claims  that  catgut  is  dissolved  by  pus,  hence 
it  will  disappear  in  a  shorter  time  in  wounds  that  suppurate.  In  my 
experience  I  have  observed  the  contrary.  In  suppurating  wounds  I 
have  seen  the  catgut  remain  unchanged  for  an  exceedingly  long 
time,  and  after  weeks  have  seen  the  ligature  come  away  in  the  secre- 
tions, having  undergone  but  little  change.  The  absorption  of  the 
catgut  ligature  is  accomplished  by  a  process  of  softening  and  infil- 
tration of  cellular  elements,  and  is  consequently  accomplished  in  the 
shortest  space  of  time  in  wounds  where  the  process  of  granulation 
is  not  impaired  by  suppuration. 

The  immediate  and  remote  effects  of  the  catgut  ligature  on  the 
vessel  also  deserve  consideration.  The  impression  prevailed  at  one 
time,  that  the  catgut  ligature  does  not  destroy  the  continuity  of  the 
artery.     This  assertion  has,  however,  met  with  opposition. 

P.  Bruns,2  in  his  experimental  work,  has  made  special  search  in 
this  direction  in  thirteen  ligations  of  arteries  in  their  continuity.  In 
the  three  specimens  obtained  ten  days  after  operation,  he  found  the 
artery  completely  severed  in  one  instance,  while  in  the  other  two 

1  Richard  Barwell,  Aneurism,  Encycl.  of  Surgery,  New  York,  voi.  iii.  p.  442. 

2  Op.  cit. 


ASEPTIC  LIGATURE.  133 

cases  a  fine  thread  of  adventitial  tissue  was  found  in  the  loops  of  the 
ligatures.  In  the  remaining  ten  cases,  where  only  traces  and  micro- 
scopical remnants  of  the  ligatures  could  be  found,  three  different 
conditions  of  things  presented  themselves. 

In  three  cases  the  vessel  was  completely  divided  in  the  same 
manner  as  after  using  the  ordinary  ligature,  but  the  intermediate 
space  between  the  vessel  ends  was  less  than  after  using  the  silk  liga- 
ture, the  space  measuring  only  from  1.5  to  3  mm.,  and  being  filled 
in  with  connective  tissue.  In  six  cases  a  solution  of  continuity  had 
apparently  not  taken  place,  and  its  existence  was  ascertained  only  by 
close  examination.  The  place  of  ligature  presented  a  somewhat 
prominent  circular  ring;  on  making  a  longitudinal  section,  the  intima 
and  media  were  found  severed,  and  their  margins  directed  towards 
the  interior  of  the  vessel,  shutting  off  its  lumen  on  both  sides  by  a 
concave  or  funnel-shaped  end.  The  interspace  between  both  blunt 
ends  was  occupied  by  a  solid  intermediary  substance  about  the  thick- 
ness of  the  ligature  and  continuous  with  the  adventitia.  The  inter- 
mediary substance  was  composed  of  young  connective  tissue  inter- 
spersed with  particles  of  the  catgut  ligature.  In  one  case  the 
continuity  of  the  vessel  was  perfect,  all  of  its  coats  being  entire. 
Evidently  the  ligature  was  not  tied  with  the  same  degree  of  firmness 
as  in  the  other  cases.  The  lumen  was  only  narrowed  by  the  ligature 
and  rendered  impermeable  by  a  thrombus. 

Bruns  is  willing  to  admit,  that  in  case  the  catgut  ligature  is 
drawn  only  sufficiently  tight  to  interrupt  the  circulation,  all  of  the 
coats  of  the  artery  remain  intact  during  the  healing  process,  and 
the  continuity  of  the  vessel  is  preserved  in  the  strictest  sense  of  the 
word.  In  the  cases  where  division  of  the  vessel  took  place,  and  a 
bridge  of  connective  tissue,  corresponding  to  the  diameter  of  the 
ligature,  formed,  he  also  asserts  that  practically  this  process  may  be 
regarded  as  similar  to  the  process  of  healing  without  loss  of  con- 
tinuity of  vessel -tunics. 

Stimson '  agrees  with  Bryant,  that  the  catgut  ligature  not  only 
primarily  divides  the  two  inner  coats  of  an  artery  like  the  ordinary 
silk  ligature,  but  that  subsequently  the  adventitia  also  gives  way 
under  the  pressure  of  the  ligature,  thus  completely  interrupting  the 
continuity  of  the  vessel.      They  affirm  that  the  bridge  of  interme- 

1  The  Antiseptic  Catgut  Ligature,  Am.  Jour.  Med.  Sciences,  1881,  p.  181. 


134  EXPERIMENTAL  SURGERY. 

diary  connective  tissue  may  impart  an  appearance   as  though  no 
division  had  occurred. 

The  results  of  my  experiments  have  demonstrated  to  my  satis- 
faction that  it  is  not  necessary  to  tie  with  sufficient  firmness  to  divide 
any  of  the  arterial  coats,  in  order  to  cause  prompt  obliteration  of  the 
artery,  and  that  in  such  instances  the  coats  of  the  vessel  are  trans- 
formed into  a  solid  string  of  connective  tissue,  the  best  possible 
result  which  can  be  obtained  after  ligature.  Even  in  case  the  liga- 
ture is  tied  with  sufficient  force  to  rupture  the  inner  coats,  the 
constricted  adventitia  may  retain  its  vitality,  and  form  a  part  and 
parcel  of  the  intermediary  connective  tissue  uniting  the  two  ends  of 
the  vessel;  and  still  further,  if  the  vitality  of  the  adventitial  coat  is 
suspended,  and  it  is  removed  by  a  slow  process  of  molecular  disin- 
tegration and  absorption,  it  is  replaced  by  tissue  elements  which  are 
converted  into  a  similar  tissue,  thus  practically  preserving  the  con- 
tinuity of  the  vessel. 

In  the  event  of  suppuration,  the  advantages  of  the  aseptic  cat- 
gut ligature  are  lost,  and  the  ligature  escapes  with  the  discharges, 
either  entire  and  unchanged,  or  in  fragments  after  it  has  undergone 
softening  and  disintegration.  Ligatures  made  of  any  other  animal 
tissue  rendered  properly  aseptic  are  disposed  of  in  the  wound  in  a 
similar  manner,  and  it  has  not  been  proved  that  any  of  them  possess 
any  advantages  over  the  well -prepared  catgut  ligature. 

Mr.  Barwell,1  in  tying  large  arteries,  uses  a  broad  ligature  made 
of  the  strong  middle  coat  of  the  ox's  aorta.  His  idea  is  to  approxi- 
mate the  intima  without  rupturing  it.  In  sixteen  cases  of  ligation 
of  large  vessels  it  proved  successful.  In  one  case  of  ligation  of  the 
femoral  artery,  haemorrhage  occurred  from  a  small  vessel  near  the 
ligature  at  the  time  of  operation;  at  the  request  of  Mr.  Barwell, 
two  more  ligatures  were  applied  within  an  inch  of  the  first  ligature, 
and  the  case  terminated  favorably.  Mr.  Barwell  still  maintains  the 
novel  belief  that  his  ligature  material  is  not  absorbed,  but  is  organ- 
ized and  becomes  a  part  of  the  living  tissue  around  it. 

Aseptic  ligatures  made  of  materials  which  are  not  capable  of 
being  absorbed  remain  in  the  wound  and  are  encysted.  All  of  these 
ligatures  are  more  prone  to  destroy  the  continuity  of  the  vessels 
than  animal  ligatures,  but  they  do  not  do  so  invariably.      Czerny's 

1  International  Encylopredia  of  Surgery,  New  York,  vol.  iii. 


THROMBOSIS  AFTER  LIGATURE.  135 

silk,  for  example,  which  is  used  next  in  frequency  to  catgut,  is  infil- 
trated with  cellular  elements,  and,  after  a  long  time,  is  partly 
absorbed  and  completely  encysted. 

XI.    Thrombosis  after  Ligature. 

One  of  the  most  serious  objections  against  the  prevalent 
doctrine  of  obliteration  of  vessels  through  the  instrumentality  of  an 
organized  thrombus,  is  the  fact  that,  in  many  instances,  coagulation 
of  the  blood  fails  to  take  place  after  tying  a  vessel  with  a  ligature, 
and  that  primary  union  of  its  inner  walls  has  been  frequently 
demonstrated  without  thrombus  formation.  The  conditions  which 
determine  intravascular  coagulation  after  ligature  are  still  not  well 
known. 

Alexander  Schmidt  has  shown  that  fibrin  as  such  does  not  exist 
in  blood,  but  that  it  is  the  product  of  a  union  between  the  two  sub- 
stances, the  fibrinogen  and  paraglobin,  under  the  influence  of  a  fibrin 
ferment,  and  he  has  further  shown  that  fibrinogen  is  contained  in  the 
plasma  of  the  blood  in  solution,  and  that  the  fibrin  ferment  and 
paraglobin  are  a  product  of  the  white  corpuscles  of  the  blood.  Para- 
globin and  fibrin  ferment  are  set  free  and  can  act  on  fibrinogen 
only  after  dissolution  of  the  white  corpuscles.  Consequently,  as 
long  as  the  integrity  of  the  white  blood-cells  is  preserved,  coagula- 
tion cannot  take  place.  As  fibrin  does  not  pre-exist  in  the  blood,  it 
is  the  product  of  chemico-vital  changes  which  take  place  before  and 
during  the  process  of  coagtQation.  During  coagulation  the  vitality 
of  the  morphological  elements  in  the  thrombus  is  lost  as  the  white 
blood-corpuscles  lose  their  identity,  and  their  protoplasm  unites  with 
the  fibrinogen  contained  in  the  serum,  and  produces  the  fibrin.  The 
endothelia  lining  the  intima,  as  long  as  they  retain  their  vitality, 
prevent  the  spontaneous  death  of  the  white  blood-corpuscles,  and 
this  prevents  the  formation  of  fibrin. 

Virchow  attributed  coagulation  to  the  diminished  motion  or 
arrest  of  the  current  of  blood  in  the  vessel,  but  this  cause  has  been 
found  insufficient  in  itself  to  produce  a  thrombus  provided  the  endo- 
thelia retained  their  normal  qualities.  Baumgarten  has  shown  that 
a  column  of  blood  can  be  kept  in  a  fluid  condition  for  weeks  within 
a  vessel  between  two  aseptic  ligatures.  If  after  several  weeks  the 
blood  was  allowed  to  escape  Uirougli  an  incision  in  the  tied  portion 


136  EXPERIMENTAL   SURGERY. 

of  the  vessel  it  coagulated  the  same  as  blood  drawn  from  any  other 
locality,  showing  that  it  had  not  lost  its  coagulating  properties  by 
its  long  confinement  between  the  ligatures. 

This  interesting  phenomenon  can  only  be  explained  by  assuming 
that  the  aseptic  ligature  preserves  the  vitality  even  of  the  torn  inner 
coats,  which  successfully  prevents  loss  of  vitality  of  any  of  the  white 
blood  cells.  Some  twenty  years  ago  the  famous  experiments  of 
Bruecke  demonstrated  that  living  tissues  resist  coagulation,  and 
Baumgarten's  experiments  most  beautifully  substantiate  this  asser- 
tion. It  is  a  well  known  fact  that  coagulation  takes  place  with  the 
greatest  degree  of  certainty  and  becomes  more  extensive  in  propor- 
tion to  the  magnitude  of  the  traumatism  inflicted  by  the  ligature, 
and  the  degree  and  extent  of  the  subsequent  inflammation. 

Until  recently  the  belief  prevailed  universally  that  foreign 
substances  introduced  into  the  circulation  invariably  produce  coagu- 
lation. This  doctrine  has  also  been  successfully  refuted.  Zahn's 
investigations  have  demonstrated  beyond  all  possible  doubt  that 
coagulation  only  follows  the  introduction  of  substances  which  have 
not  been  properly  disinfected.  He  introduced  aseptic  pieces  of 
glass  and  rubber,  and  never  observed  coagulation  following  this 
procedure. 

Hueter,  in  speaking  of  thrombosis  in  veins,  refers  to  our  subject 
as  follows:  "Whether  by  following  antiseptic  precautions  the 
formation  of  a  thrombus  can  be  prevented  with  the  same  degree 
of  certainty  as  in  the  case  of  arteries  remains  an  open  question. 
It  is  certain,  however,  that  septic  infections  favor  coagulation  in 
veins."1  Of  this  latter  assertion  clinical  experience  furnishes  abun- 
dant proof.  It  is  more  than  probable  that  during  the  progress  of 
many  of  the  infectious  diseases,  many  of  the  lining  endothelia  of  the 
intima  are  destroyed,  and  that  the  white  corpuscles  coming  in 
contact  with  dead  tissue  lose  their  vitality  and  produce  thrombosis. 

But  even  under  the  old  pre-antiseptic  treatment  thrombus 
formation  was  by  no  means  a  constant  result  after  ligation.  Walther, 
in  twenty- eight  experiments  to  determine  this  question,  found  a 
thrombus  in  both  ends  of  the  vessel  eighteen  times.  In  one  case 
there  was  no  thrombus  on  either  side  of  the  ligature,  and  in  one 
only  on  the  cardiac  side,  while  in  the  remaining  eight  cases  the 
thrombus  was  found  only  in  the  distal  end  of  the  artery. 
1  Grundriss  der  Chirurgie,  1880,  vol.  i.  p.  148. 


ORGANIZATION   OF   THROMBUS.  131 

Porta  has  made  the  largest  number  of  experiments  to  ascertain 
the  relative  frequency  of  thrombus  formation  after  ligature.  In  two 
hundred  and  fifty  cases  of  ligation  of  large  arteries  in  animals,  in 
which  the  vessels  were  examined  for  this  purpose,  he  found  in  thirty- 
five  cases  no  traces  of  a  thrombus,  and  yet  he  observed  only  three 
cases  of  secondary  haemorrhage  after  four  hundred  ligations. 

Schumann1  made  fifty-four  experiments  on  dogs  and  rabbits 
in  order  to  study  the  provisional  and  definitive  closure  of  vessels 
after  ligature.  Thrombus  formation  had  occurred  in  only  32  per 
cent,  of  the  cases,  and  the  coagulum  in  all  of  these  cases  was  usually 
small.  It  is  evident  from  these  statistics  that  thrombus  formation 
after  ligature  frequently  fails  to  take  place,  and  that  in  this  event 
closure  of  the  vessel  is  effected  by  tissue  proliferation  from  the 
vessel  tunics.  It  would  hardly  appear  reasonable  to  assume  with 
Kocher,  that  in  these  cases  a  thrombus  so  minute  in  size  as  to  elude 
detection  by  the  naked  eye  might  still  exist,  and  perform  the  difficult 
task  of  obliterating  the  lumen  of  the  vessel. 

XII.    Organization  of  Thrombus. 

By  organization  of  a  thrombus  we  understand  that  some  of  its 
morphological  elements  retain  their  vitality  and  power  of  tissue 
proliferation.  In  this  sense  the  term  is  used  by  all  authors  who 
have  attributed  to  fibrin,  white  blood-corpuscles  and  red  blood-cor- 
puscles the  property  of  being  converted  into  connective  tissue.  If 
the  intra-vascular  thrombus  possesses  this  quality,  it  is  certainly  an 
exception  to  the  general  rule,  as  extravasations  of  blood  in  any  other 
locality  of  the  body  are  never  known  to  undergo  organization. 
Under  the  most  favorable  circumstances  they  are  destined  to  suc- 
cumb to  retrograde  metamorphosis,  leaving  eventually  nothing  but 
haematoidin  crystals  as  landmarks  of  their  former  existence. 

Serous  membranes  afford  a  favorable  surface  for  rapid  absorp- 
tion of  blood,  so  much  so  that  the  peritoneal  cavity  has  been 
utilized  for  the  purpose  of  performing  transfusion  of  blood.  Copious 
effusions  of  blood  into  joints  are  usually  promptly  absorbed,  leaving 
no  permanent  ill  results  as  far  as  the  functions  of  the  joints  are 
concerned.  Immense  extravasations  into  the  cellular  tissue  about  the 
seat  of  fracture,  or  as  the  result  of  other  injuries,  are  completely 

1  YirHiow  ii.  Hirsch'a  Jahresb.  vol.  Li.  1874,  p.  377. 


138  EXPERIMENTAL   SURGERY. 

absorbed  in  a  remarkably  short  time,  provided  suppuration  is  pre- 
vented. The  anterior  chamber  of  the  eye,  from  the  peculiar 
anatomical  structure  of  its  walls,  is  an  exceedingly  favorable  locality 
for  successful  tissue  transplantation,  as  has  been  demonstrated  by 
Dorremal  and  Goldzieher,  and  yet  every  oculist  can  testify  to  the 
fact  that  extravasations  of  blood  in  this  locality  never  undergo 
organization,  but  are  usually  promptly  removed  by  absorption.  As 
an  additional  factor,  it  may  also  be  mentioned  that  the  intra-vas- 
cular  thrombus  is  located  disadvantageously  as  far  as  organization 
is  concerned,  the  intima  and  media  separating  it  from  the  nearest 
vascular  supply. 

The  assertion  made  by  Lister  that  blood-clots  in  wounds  under 
the  antiseptic  treatment  become  organized,  certainly  does  not  corre- 
spond with  facts.  If  blood-clots  in  the  interior  of  the  tissues  of  the 
body,  safely  protected  from  any  possible  source  of  infection,  invari- 
ably disappear  by  absorption,  there  is  no  good  reason  to  believe  that 
they  will  undergo  any  other  changes  when  located  in  wounds.  The 
clot  itself  is  not  organized,  but  simply  serves  the  useful  purpose  of 
furnishing  a  favorable  soil  for  the  lodgment  and  propagation  of  new 
tissue-elements  from  the  adjacent  wound  surfaces.  In  this  sense 
the  organization  of  the  clot  is  accepted  by  Volkmann.1  He  believes 
that  the  blood  clot  between  the  broken  ends  of  the  bone  in  com- 
pound fractures  serves  primarily  the  purpose  of  a  soft  cement 
substance  which,  under  the  protection  of  antiseptic  precautions,  is 
gradually  displaced  by  substitution,  and  its  space  occupied  by 
permanent  tissue. 

XIII.     Formation  of  Cicatrix  in  Blood-Vessels  after 

Ligature. 

The  ligature  fulfills  a  two-fold  object:  1.  It  constitutes  the 
most  scientific  and  reliable  provisional  haemostatic,  interrupting  at 
once  the  physiological  function  of  the  vessel  at  the  point  of  applica- 
tion. 2.  It  brings  the  vessel  walls  in  mutual  contact,  and,  by 
maintaining  uninterrupted  apposition  for  a  sufficient  length  of  time, 
it  induces  an  active  tissue  proliferation  which  is  destined  to  produce 
definitive  obliteration  of  the  lumen  of  the  vessel.     The  immediate 

1  Die  Behandlung  der  complicirteu  Fracturen.     Volkmann's    Sammlung 
klin.' Vortrage,  No.  134. 


FORMATION   OF  CICATRIX   AFTER   LIGATURE.  139 

effect  of  the  ligature  in  arresting  the  circulation  was  well  known 
even  to  those  who  first  resorted  to  its  use,  but  the  secondary  changes, 
the  definitive  closure  of  vessels  by  cicatrization,  has  been  a  subject 
concerning  which  there  has  prevailed  the  greatest  diversity  of 
opinion  and  which '  still  remains  a  prolific  object  of  study  and 
investigation. 

The  researches  of  Jones  laid  the  foundation  for  an  intelligent 
and  rational  study  of  the  process  of  cicatrization  in  blood-vessels 
after  ligature.  Various  theories  have  been  advanced  which  were 
intended  to  furnish  an  explanation  of  the  process  of  obliteration,  or 
to  point  out  the  particular  tissue  which  supplies  the  material  for  the 
cicatrix.  The  production  of  cicatricial  tissue  within  the  blood- 
vessels has  been  attributed  to:  1.  Adhesive  inflammation  and 
plastic  exudation  at  the  seat  of  ligature  without  reference  to  any 
histological  changes.  '2.  Fibrin.  3.  White  blood-corpuscles.  4.  Red 
blood-corpuscles.  5.  Immigration  corpuscles.  6.  Connective  tissue. 
7.  Endothelia. 

XIT.     Formation  of  Cicatrix  by  Adhesive  or  Plastic 
Inflammation. 

The  existence  of  adhesive  inflammation  has  always  been  recog 
nized  as  an  important  element  in  effecting  permanent  closure  of  a 
vessel  after  ligature.     Under  this  head  will  be  mentioned  the  patho- 
logical views  of  older  writers  who  studied  the  process  of  cicatrization 
independently  of  any  accurate  histological  knowledge. 

Celsus  believed  that  the  definitive  obliteration  of  the  vessel  was 
due  to  retraction  of  the  artery  and  tumefaction  of  the  connective 
tissue  around  it.  Galen  asserted  that  permanent  closure  takes  place 
by  a  cicatrix  which  closes  the  wound  in  the  vessel,  believing  that 
the  arterial  walls  unite  only  in  exceptional  cases.  Ponte^iu  regarded 
the  inflamed  para-vascular  tissue  as  the  most  important  element 
in  the  obliterating  process.  John  and  Benjamin  Bell  believed  that 
an  artery  is  occluded  by  a  plastic  exudation  which  takes  place  from 
its  inner  walls  and  the  divided  ends. 

Scarpa,  who  compared  the  tunica  intima  with  serous  membranes, 
and  attributed  to  it  the  same  tendency  to  assume  inflammatory 
changes  and  form  speedy  and  firm  adhesions,  commits  himself  on 


140  EXPERIMENTAL  SURGERY. 

this  subject  as  follows:1  "The  union  of  the  two  opposite  sides  of 
an  artery,  as  I  have  mentioned  several  times,  only  takes  place  by 
means  of  the  adhesive  inflammation,  to  excite  which,  and  in  order 
that  it  may  produce  the  desired  effect,  it  is  necessary  that  the  artery 
be  not  insulated  too  much,  or  beyond  the  limits  of  the  ligature;  that 
the  degree  of  pressure  be  such  as  to  put  and  keep  the  two  opposite 
sides  of  it  in  complete  and  firm  contact;  that  the  irritation  caused  by 
the  pressure  be  sufficient  to  produce  inflammation  in  the  proper 
coats  of  the  artery  without  their  passing  immediately  into  a  state  of 
mortification  from  a  want  of  vitality.  If  this  degree  of  pressure  be 
too  small,  the  artery  does  not  inflame  sufficiently  and  is  not  obliter- 
ated, but  is  rather  wasted  slowly  and  then  bursts ;  if  the  pressure  be 
too  great,  and  especially  upon  an  artery  insulated  in  a  greater  space 
than  is  requisite  for  the  ligature,  it  mortifies,  ulcerates,  and  opens 
before  the  sides  of  it  have  adhered  to  each  other,  both  at  the  place 
of  ligation  and  for  a  certain  space  above  and  below  it." 

Porta  placed  great  stress  on  the  importance  of  primary  union 
of  the  wound,  and  the  appearance  of  an  external  plastic  ring  at  the 
seat  of  the  ligature,  in  securing  permanent  occlusion  of  a  vessel. 
He  also  pointed  out  how  suppuration  would  interfere  in  obtaining 
the  most  favorable  results  after  ligation.  Jones  and  Travers  almost 
ignored  the  importance  of  the  thrombus  in  effecting  closure  of  a 
vessel,  and  assigned  to  the  traumatic  inflammatory  exudation  almost 
exclusively  the  function  in  accomplishing  this  object.  They  claimed 
that  the  ligature  acts  as  an  irritant  to  the  walls  of  the  vessel,  plastic 
exudation  taking  place  into  its  lumen,  the  torn  intima  and  media 
becoming  adherent,  thus  permanently  closing  the  canal. 

Kirkland  and  White  maintained  that  the  coats  of  arteries  near 
the  ligature  unite  by  plastic  lymph,  and  that  the  coagulum  is  not 
only  useless  but  may  prove  detrimental  by  interfering  with  such 
union. 

After  Virchow  in  his  researches  on  thi-ombosis  and  embolism 
had  demonstrated  that  the  intima  is  not  susceptible  of  inflammation, 
pathologists  again  turned  their  attention  to  the  importance  of  the 
thrombus  as  an  active  agent  in  the  process  of  cicatrization.  Rokit- 
ansky,2  in  opposition  to  Virchow,  again  claimed  that  the  final  oblitera- 

1  A  Treatise  on  the  Anatomy,  Pathology,  and  Treatment   of  Aneurism, 
trans,  by  Henry  Wishart,  1808,  p.  277. 

2  Handbuch  der  Speciellen  pathologischen  Anatomie.     Wien,  1844,  p.  616. 


FORMATION   OF  CICATRIX   AFTER   LIGATURE.  141 

tion  of  an  artery  could  take  place  without  a  thrombus,  in  a  similar 
manner  as  in  the  vessels  of  the  umbilical  cord  and  the  ductus  Botalli. 

Ph.  von  Walther '  says  that  the  tunics  of  in  juried  arteries  inflame 
in  a  similar  manner  as  other  wounded  organs.  The  phlogistic  exu- 
dation takes  place  first  in  the  external  coat,  somewhat  later  in  the 
middle  coat,  and  last  on  the  free  surface  of  the  internal  tunic. 

Cruveilhier,  Castleman,  and  Forster  also  ignored  the  importance 
of  the  thrombus,  and  pointed  to  the  tissues  of  the  vessel-walls  as  the 
active  agents  in  the  obliterating  process.  All  of  the  authorities  who 
mention  adhesive  inflammation  as  the  means  by  which  vessels  are 
permanently  closed,  assign  to  the  thrombus  only  an  unimportant  or 
entirely  passive  role,  but  at  the  same  time  they  do  not  point  out  the 
particular  tissue  element  which  is  supposed  to  furnish  the  material 
for  the  cicatrix. 

Later  researches  have  aimed  to  limit  the  process  to  some  special 
structure  and  to  study  and  demonstrate  the  minute  processes  by 
which  obliteration  is  accomplished.  In  one  of  our  recent  American 
text- books  on  surgery,  the  process  of  obliteration  in  an  artery  is 
described  as  follows:  "The  permanent  closure  and  final  and  com- 
plete obliteration  of  these  vessels  (arteries)  is  effected  by  their  con- 
tinued contraction,  by  the  effusion  of  fibrin  within  and  around  the 
vessels,  and  at  length  by  the  conversion  of  all  their  coats  into  simple 
cords  of  connective  tissue.  Even  these  latter  may  in  the  course  of 
time  disappear."2 

XA\    Formation  of  Cicatrix  from  Fibrin. 

All  pathologists  who  ascribe  to  any  of  the  pre-existing  morpho- 
logical elements  of  the  thrombus  the  active  part  in  the  process  of 
cicatrization,  as  a  matter  of  necessity  consider  the  presence  of  the 
thrombus  essential  in  the  process  of  obliteration. 

John  Hunter  maintained  that  the  fibrin  in  the  clot  is  capable  of 
undergoing  organization,  and  is  the  active  agent  in  producing  per- 
manent closure  of  a  vessel  after  ligation.  He  based  his  assertion  on 
the  examination  of  a  thrombus  taken  from  a  crural  artery,  which  he 
injected  from  the  lumen  of  the  vessel  and  found  that  it  contained  a 
network  of  vessels.      To  satisfy  himself  that  organization  of  the 

1  System  der  Chirurgie.     Carlsruhe  u.  Freiburg,  184:?.  B.  i.  p.  253. 

2  Hamilton,  The  Principles  and  Practice  of  Surgery,  1879,  p.  176. 


142  EXPERIMENTAL  SURGERY. 

thrombus  takes  place,  he  applied  a  double  ligature  to  the  carotid 
artery  of  a  dog,  and  on  examination  of  the  specimen  some  time  after- 
ward he  found  his  conclusion  verified. 

Grendrin,  who  repeated  the  experiments  of  Hunter,  says:  "If  a 
quantity  of  blood  is  included  between  two  ligatures  in  an  artery  or 
vein,  it  coagulates,  and,  as  is  well  known,  the  serum  is  absorbed  and 
a  slight  imnanimation  takes  place  in  the  walls  of  the  vessel.  The 
different  parts  of  the  thrombus  are  decolorized,  a  thin  layer  of  coagu- 
lated lymph  diffuses  itself  over  the  inner  walls  of  the  vessels  which 
effects  adhesion  between  thrombus  and  vessel -walls,  the  thrombus 
finally  undergoes  organization  and  cicatrization." 

Andral  supposed  that  he  had  demonstrated  in  a  satisfactory 
manner  that  fibrin  in  cases  of  pleuritic  exudations  and  pseudo-mem- 
branes is  converted  into  connective  tissue,  and  his  teachings  were 
generally  accepted.  Henle  also  claimed  that  fibrin  is  converted  into 
connective  tissue,  and  that  it  constituted  the  most  important  element 
of  the  thrombus.  Zwicky,  a  pupil  of  Henle,  was  the  first  to  give  an 
accurate  microscopical  description  of  the  appearances  in  vessels  after 
ligation.  In  accordance  with  the  views  of  his  preceptor,  he  asserted 
that  the  blood  corpuscles  play  only  a  passive  part  in  the  process  of 
organization  of  the  clot. 

As  late  as  1872,  Billroth  writes:  "Coagulated  fibrin  may,  by 
aid  of  cells,  be  transformed  into  connective-tissue  inter-cellular 
substance,  although  I  cannot  decide  whether  this  be  due  to  a  true 
metamorphosis,  or  to  a  gradual  substitution  of  cell  protoplasms  for 
disappearing  fibrin." ' 

It  is  almost  unnecessary  to  say  that  at  the  present  time  no  one 
can  be  found  who  claims  that  fibrin  is  capable  of  being  transformed 
into  connective  tissue,  but  that  wherever  found,  it  invariably  dis- 
appears after  a  time  by  molecular  disintegration  and  absorption. 
Physiology  teaches  us  that  fibrin  does  not  pre-exist  in  living  blood, 
but  that  it  is  formed  as  the  result  of  chemico-vital  changes  during 
coagulation,  hence  we  would,  a  priori,  conclude  that  such  a  substance 
is  not  capable  of  being  elaborated  into  tissue  endowed  with  a  higher 
degree  of  vitality. 

1  General  Surgical  Pathology  and  Therapeutics,  trans,  by  C.  E.  Hackley, 
New  York,  1872. 


FORMATION    OF  CICATRIX  AFTER   LIGATURE.  143 

XVI.    Formation  of  Cicatrix  from  White  Blood-Corpuscles. 

After  Virchow  bad  shown  that  adhesive  inflammation  of  the 
intima  is  incompatible  with  its  structure,  pathologists  again  turned 
their  attention  to  the  thrombus  as  the  active  medium  of  the  process 
of  obliteration.  The  organization  of  the  thrombus  now  became 
a  favorite  study.  Stilling  and  Zwicky  not  only  claimed  that 
the  thrombus  undergoes  organization,  but  they  were  also  among  the 
first  to  describe  a  vascular  network  in  the  thrombus;  the  vessels, 
according  to  their  observations,  communicating  with  and  originating 
from  the  lumen  of  the  vessel. 

Virchow,  Billroth,  and  O.  Weber  referred  the  organization  of  the 
thrombus  to  the  presence  in  it  of  the  white  blood- corpuscles.  Czerny 
and  Schumann  attributed  it  to  the  same  cause.  They  traced  step  by 
step  the  part  taken  by  these  corpuscles  in  the  process  of  organization 
of  the  clot.  Pirogoff,  Thierfelder,  Gerstacker,  and  Boner,  studying 
the  fate  of  the  white  blood-corpuscles  in  subcutaneous  tenotomies, 
found  them  capable  of  transformation  into  new  connective  tissue. 

The  conclusions  at  which  O.  Weber  arrived  may  be  summarized 
as  follows: 

1.  The  red  blood-corpuscles  and  fibrin  of  the  clot  disintegrate 
and  disappear  by  absorption. 

2.  The  colorless  blood-corpuscles  in  the  clot,  a  few  hours  after 
the  application  of  the  ligature,  enter  into  a  transformation  into 
spindle-shaped  cells. 

3.  After  a  few  days  the  projections  thrown  out  by  these  cells 
may  be  seen  to  unite  with  each  other,  and,  by  arranging  themselves 
in  rows,  plainly  assume  the  shape  of  new  vessels. 

4.  The  youngest  vessels  are  formed  in  the  peripheral  portion 
of  the  clot. 

5.  During  the  third  and  fourth  weeks  the  vascularization  of 
the  thrombus  is  completed,  the  vessel  having  formed  anastomoses 
with  the  vasa  vasorum  of  the  adventitia.  At  the  point  of  ligature 
where  the  intima  and  media  have  been  lacerated,  the  vessels  of  the 
adventitia  enter  the  thrombus  directly;  further  from  the  ligature 
they  penetrate  through  the  two  inner  coats  and  enter  the  thrombus. 

6.  About  the  fiftieth  to  the  sixtieth  day  the  thrombus  is 
traversed  everywhere  by  vessels,  more  especially  at  the  periphery. 
A  large  vessel  is  often  found  in  the  centre  of  the  clot. 


144  EXPERIMENTAL  SURGERY. 

7.  During  the  process  of  cicatrization,  the  vessels  in  the 
thrombus  disappear,  the  lumen  of  the  vessel  becomes  narrower,  and 
is  finally  completely  obliterated. 

8.  The  cicatricial  tissue  is  the  exclusive  product  of  the  white 
blood-corpuscles. 

9.  The  white  blood-corpuscles  multiply  very  rapidly  by  seg- 
mentation. 

10.  The  endothelia  of  the  new  blood-vessels  in  the  thrombus 
are  produced  exclusively  from  the  white  blood  corpuscles.1 

Kocher2  has  studied  the  organization  and  vascularization  of  the 
thrombus  after  ligature,  and  sustains  the  views  entertained  by 
Weber.  He  injected  the  vessels  from  the  lumen  of  the  artery,  and 
examined  transverse  sections  under  the  microscope. 

I  will  give  the  description  of  one  of  his  specimens:  On  Decem- 
ber 24,  1807,  he  ligated  the  right  carotid  artery  of  a  dog,  and  dusted 
finely  powdered  cinnabar  over  the  exposed  portion  of  the  vessel  to 
indicate  subsequently  the  exact  location  of  the  ligature.  The  animal 
was  killed  January  11,  1868.  The  operation  wound  was  healed. 
The  vessel  was  injected  with  gelatine  stained  with  Berlin  blue,  and 
hardened  at  first  in  a  solution  of  chromate  of  potassa,  and  afterward 
in  alcohol ;  when  it  was  sufficiently  hardened,  it  was  thoroughly  dried 
and  inclosed  in  a  coating  of  paraffin  for  the  purpose  of  making 
microscopical  sections.  The  decolorization  of  the  thrombus  was 
more  complete  near  the  ligature  than  towards  the  free  lumen  of  the 
vessel.  The  proximal  end  of  the  thrombus  was  adherent  only  to 
one  side  of  the  vessel,  so  that  the  injection  material  penetrated  the 
other  side  between  the  vessel-wall  and  the  thrombus. 

From  the  free  surface  of  the  central  end  of  the  thrombus  a 
central  vessel  of  considerable  size  was  seen  to  enter  the  thrombus; 
from  it  smaller  vessels  branched  off  and  penetrated  the  thrombus  in 
different  directions,  forming  a  beautiful  network  of  capillary  vessels, 
which  left  no  doubt  in  his  mind  that  the  channels  were  real  blood- 
vessels and  not  an  artificial  product.  Wherever  the  thrombus  was 
adherent  to  the  intima,  the  latter  showed  small  vessels  from  the 
adventitia,  while  the  free  surfaces  of  the  intima  remained  non- 
vascular.    Nearer  the  ligature  the  vascular  network  from  the  adven- 

1  V.  Pitha  u.  Billroth's  Chirurgie,  i.  1. 

2  Ueber  die   feineren  Vorgange   bei   der  Blutstillung   durch  Acupressur, 
Ligatur  und  Torsion,  Archiv  f.  Klin.  Chirurgie,  B.  xi.  S.  660. 


FORMATION   OF   CICATRIX   AFTER   LIGATURE.  145 

titia  was  more  fully  developed,  supplying  numerous  branches  to  the 
inner  coats  of  the  artery.  The  torn  intima  at  the  seat  of  ligature 
was  arranged  in  folds,  its  free  and  irregular  margins  sending  pro- 
longations into  the  thrombus.  The  media  was  also  divided  by  the 
ligature,  so  that  the  thrombus  penetrated  between  its  fibres.  While 
the  vascularity  of  the  vessel-wall  increased  towards  the  ligature,  the 
vessels  in  the  thrombus  became  smaller  in  the  same  ratio,  disappear- 
ing completely  near  the  ligature. 

These  appearances  satisfied  him  that  the  vascular  supply  of  the 
thrombus  is  derived  directly  from  the  free  lumen  of  the  vessel,  while 
the  vasa  vasorum  increase  in  size  and  number,  and  distribute  branches 
to  the  inner  tunics  over  an  area  corresponding  with  the  adherent 
portions  of  the  thrombus.  He  agrees  with  O.  Weber  that  canalization 
of  the  thrombus  initiates  organization.  He  also  made  a  number  of 
experiments  where  the  conditions  for  thrombus  formation  were 
exceedingly  unfavorable,  by  tying  arteries  in  close  proximity  to  a 
large  collateral  branch.  In  all  cases  where  the  experiment  proved 
successful,  he  found  the  two  inner  tunics  ruptured,  and  in  every 
instance  no  direct  union  of  the  lacerated  tissues,  but  cicatrization  was 
always  the  result  of  a  thrombus,  which  in  some  instances  was  exceed- 
ingly small,  almost  microscopical  in  size. 

For  the  purpose  of  proving  that  the  tissues  of  the  arterial  coats 
take  no  active  part  in  the  process  of  obliteration,  he  made  the  fol- 
lowing experiment:  The  right  carotid  artery  of  a  dog  was  tied 
December  24,  1867,  in  two  places,  2  cm.  apart,  the  blood  in  the 
intermediate  space  having  been  squeezed  out  between  two  fingers 
before  tying  the  peripheral  ligature.  Cinnabar  was  dusted  over  the 
vessel  in  the  wound.  The  animal  was  killed  January  11,  1868.  The 
wound  was  healed.  The  vessel  on  the  cardiac  side  was  closed  by  an 
extensive  adherent  thrombus.  Between  the  ligatures  the  vessel  con- 
tained a  very  small  adherent  thrombus,  the  greater  portion  of  the 
lumen  being  empty.  Transverse  section  through  this  portion  of  the 
artery  revealed  the  star-shaped  lumen  of  the  vessel,  the  folds  of 
the  intima  being  in  contact  but  not  adherent.  No  proliferation  of  the 
vessel-wall  or  the  epithelium  could  be  observed.  The  staining 
material  was  found  diffused  in  the  para-vascular  connective  tissue 
and  the  outer  layers  of  the  adventitia,  but  had  failed  to  reach  the 
inner  tunics  or  lumen  of  the  vessel.       This  experiment  convinced 


146  EXPERIMENTAL  SURGERY. 

him  that  the  intact  vessel -wall  does  not  participate  in  the  obliterating 
process. 

His  numerous  acupressure  and  torsion  experiments  showed 
that  wherever  obliteration  of  the  vessels  takes  place  it  is  due  to 
injury  done  to  the  intima,  however  slight  that  may  be,  followed  by 
thrombosis,  vascularization,  and  organization  of  the  thrombus,  and 
cicatrization  by  transformation  of  the  white  blood-corpuscles  into 
cicatricial  connective  tissue,  which  finally  approximates  the  inner 
vessel-walls,  and  holds  them  in  permanent  contact.  He  denies  the 
possibility  of  direct  union  between  the  surfaces  of  the  intima  without 
the  intervention  of  a  thrombus.  The  views  so  strongly  advocated  by 
Virchow,  O.  Weber,  and  Kocher  have  been  indorsed  for  the  last  forty 
years  by  a  majority  of  the  most  prominent  pathologists,  and  have 
found  their  way  into  most  of  our  text-books. 

Paget  writes:  "The  artery  between  the  ligature  and  the  nearest 
collateral  branch  contracts  and  in  some  instances  obliterates  the 
whole  portion  of  the  vessel,  losing  its  anatomical  features,  and  is 
gradually  converted  into  a  fibrous  string.  The  colorless  blood- 
corpuscles  in  the  clot  elongate  into  spindles,  or  form  stellate 
corpuscles,  such  as  are  seen  in  young  connective  tissue,  forming  by 
anastomoses  a  network  which  traverses  the  clot  in  all  directions." ' 

Paget,  however,  recognises  the  part  performed  by  the  vessel - 
walls,  as  he  further  states:  "The  clot,  with  the  aid  of  the  plastic 
inflammatory  exudation,  becomes  firmly  adherent  to  the  inner  walls 
of  the  vessel."  Billroth,  after  his  description  of  organized  thrombi, 
accounts  for  the  presence  of  the  embryonal  connective-tissue  cells  in 
the  following  manner:  "After  having  abandoned  the  idea  of  pro- 
liferation of  stable  tissue-cells  in  inflammation,  we  can  no  longer  talk 
of  a  proliferation  of  the  intima  in  the  old  sense.  But  whence  come, 
then,  these  newly  formed  cells  ?  I  have  no  doubt  that  they  originate 
from  the  white  blood-cells,  which  have  been  partly  inclosed  in  the 
thrombus,  partly  may  have  wandered  into  it,  according  to  the  observa- 
tions of  Von  Recklinghausen  and  Bubnoff."2     • 

1  Lectures  on  Surgical  Pathology,  1870. 

2  General  Surgical  Pathology  and  Therapeutics,  trans,  by  C.  E.  Hackley, 
A.M.,  M.D.     N.  Y.  1872,  p.  108. 


FORMATION   OF  CICATRIX  AFTER   LIGATURE.  147 

XVII.    Formation  of  Cicatrix  from  Red  Blood-Corpuscles. 

The  remaining  pre-existent  histological  elements  in  the  throm- 
bus, the  red  blood-cells,  have  been  considered  by  the  preceding 
authorities,  as  passive  elements  destined  to  undergo  granular  degen- 
eration and  to  disappear  by  absorption.  A  few  pathologists,  how- 
ever, among  them  Kindfleisch,  Adreef,  and  Koslowsky,  assign  to 
them  an  active  part  in  the  organization  of  the  clot,  for  the  reason  that 
they  have  observed  that  instead  of  undergoing  molecular  disintegra- 
tion they  gradually  lose  their  coloring  material,  and  by  a  series  of 
successive  changes  they  are  transformed  into  white  blood-corpuscles 
and  become  endowed  with  all  the  intrinsic  vital  properties  possessed 
by  these  elements.  They  maintain  for  the  red  blood -corpuscles  the 
same  active  role  in  the  organization  of  the  clot  and  the  process  of 
cicatrization  that  has  been  assigned  to  the  white  blood-corpuscles. 

XVIII.     Formation  of   Cicatrix  from  Immigration 
Corpuscles. 

Soon  after  the  discovery  of  the  wandering  corpuscle  this 
element  was  supposed  to  be  the  principal  agent  in  the  process  of 
tissue  regeneration  and  in  the  formation  of  pathological  products. 
The  obscure  and  much  vexed  question  of  obliteration  of  vessels 
after  ligation  found  a  ready  interpretation  by  assuming  that  these 
wandering  corpuscles,  endowed  with  inherent  properties  to  produce 
new  tissue,  would  penetrate  the  walls  of  the  vessel  and  enter  its 
lumen,  and  there,  by  being  converted  into  connective  tissue,  would 
effect  definitive  closure.  The  functions  previously  attributed  to  the 
pre-existing  white  blood-corpuscles  in  the  thrombus  were  now 
assigned  to  immigration  corpuscles  by  a  number  of  observers. 

Von  Recklinghausen  adopted  this  theory,  and  was  soon  followed 
by  one  of  his  pupils,  Bubnoff,  who  wrote  a  long  and  interesting  article 
on  this  subject.1  In  order  to  prove  that  cells  enter  the  vessel  from 
without,  he  tied  the  jugular  vein  in  animals,  and  applied  finely 
powdered  cinnabar  to  the  vessel  at  the  seat  of  ligature  before  closing 
the  wound.  From  the  well-known  capacity  of  the  white  blood- 
corpuscles  to  absorb  finely  divided  substances,  he  expected  that  they 
would  absorb  some  of  these  minute  granules  of  the  coloring  material 

1  Ueberdie  Organization  des  Thrombus,  Centralblatt  fiir  die  Medicinische 
WirtHenschaften.     No.  48.     18<57. 


148  EXPERIMENTAL   SURGERY. 

and  convey  them  into  the  vessel,  which  would,  on  subsequent  exami- 
nation, render  their  identification  in  the  lumen  an  easy  matter,  and 
furnish  positive  proof  of  their  passage  through  the  vessel  walls. 
He  was  not  disappointed  in  his  expectations,  as  in  all  of  his  experi- 
ments he  found  on  microscopical  examination  corpuscles  charged 
with  granules  of  cinnabar  in  the  interior  of  the  vessels. 

His  results  lead  him  to  adopt  the  following  conclusions:  The 
colorless  blood-corpuscles  in  the  thrombus  lose  their  property  to 
migrate  after  coagulation  has  taken  place,  consequently  they  take  no 
active  part  in  cell-proliferation.  The  organization  of  the  thrombus 
is,  to  a  great  extent,  accomplished  by  cells  which  enter  the  veins 
from  without.  Most  of  the  cells  are  derived  from  the  vasa  vasorum 
and  the  adjacent  para -vascular  spaces.  Kocher  repeated  these 
experiments  on  arteries,  but  failed  to  obtain  the  same  results. 

Thiersch  objects  to  the  conclusions  advanced  by  Bubnoff,  claim- 
ing that  the  discovery  of  cells  containing  granules  of  cinnabar  in  the 
interior  of  the  vessels  is  no  proof  that  the  cells  entered  from  without, 
as  the  coloring  material  might  have  entered  the  vessel  with  fluids 
passing  through  spaces  in  the  vessel-walls,  without  the  assistance  of 
any  morphological  elements. 

Raab  admits  that  leucocytes  do  penetrate  the  coats  of  veins,  but 
does  not  believe  that  they  take  any  part  in  the  obliteration  of  the 
vessel.  Durante,  Cornil,  and  Ranvier  have  demonstrated  that  leuco- 
cytes traverse  the  walls  of  a  vessel  only  when  this  has  been  tied  with 
a  double  ligature,  causing  death  of  the  included  vessel,  and  that 
leucocytes  travel  only  through  this  dead  tissue.  Klein1  claims  that 
endothelial  cells  are  converted  into  leucocytes,  and  that  these  are 
instrumental  in  the  process  of  cicatrization. 

Seuftleben2  has  demonstrated  beyond  all  doubt  that  leucocytes 
do  enter  the  walls  of  veins  which  have  been  separated  from  all 
vascular  connections.  He  removed  sections  of  veins,  disinfected  them 
thoroughly,  tied  both  ends  firmly,  and  introduced  them  into  the 
peritoneal  cavity  of  living  animals.  He  killed  the  animals  at  variable 
periods  after  the  operation  and  found  these  bloodless  transplanted 
pieces  of  vein-tissue  in  most  instances  adherent  and  encysted.    Even 

1  The  Anatomy  of  the  Lymphatic  System,  London,  1873,  I. 

2  Ueber  den  Verschluss  der  Blutgefasse   nach   Unterbindung,  Virchow's 
Archiv.,  B.  77,  S.  421. 


FORMATION   OF  CICATRIX   AFTER   LIGATURE.  149 

after  a  comparatively  short  time  he  found  the  interior  of  the  vein 
occupied  by  masses  of  epithelial  cells,  spindle-shaped  cells,  round 
and  even  giant  cells.  The  last  mentioned  cells  were  evidently 
intended  to  accomplish  the  work  of  absorption  of  the  transplanted 
tissues.  To  all  of  these  cells  Seuftleben  assigned  an  extra-vascular 
origin. 

N.  Schultz1  studied  the  influence  of  the  migration  corpuscles  in 
cicatrization  in  blood-vessels  by  applying  a  double  ligature  and 
excluding  the  blood  from  the  intermediate  portion  of  the  vessel.  He 
operated  on  arteries.  In  examining  specimens  a  short  time  after 
operation,  he  scraped  the  intima,  and  observed  incipient  degenerative 
change  in  the  endothelia  and  no  attempt  at  proliferation.  In  speci- 
mens two  days  old  he  found  white  blood-corpuscles  in  the  lumen  of 
the  intermediary  portion  of  the  vessel,  which  he  believed  entered  from 
without,  and  which  were  eventually  converted  into  connective-tissue. 
In  specimens  one  hundred  and  twenty- eight  to  one  hundred  and  fifty- 
five  days  old,  the  vessel  between  the  two  ligatures  consisted  of  a  string 
of  loose  connective-tissue  in  which  no  trace  of  the  original  tissues 
of  the  arterial  coat  remained.  Cicatrization  progressed  more  rapidly 
in  the  femoral  than  in  the  carotid  arteries.  In  one  case  where  only 
one  ligature  was  applied  he  also  observed  no  proliferation  on  the 
part  of  the  endothelial  cells,  but  in  this  instance  he  believed  that 
the  process  of  organization  and  cicatrization  of  thrombus  was  due  to 
the  presence  of  the  white  corpuscles  in  the  thrombus. 

Uhle  and  Wagner2  credit  the  wandering  corpuscle  with  at  least 
a  part  of  the  work  required  in  the  obliteration  of  a  vessel.  Their 
description  of  the  cicatrix  formation  commences  with  the  following 
allusion  to  this  subject:  "The  organization  of  a  thrombus  is  certainly 
not  effected  by  an  exudation  on  the  inner  surface  of  the  walls  of  a 
vessel,  nor  by  the  white  blood-corpuscles  contained  in  it;  perhaps  at 
least  in  part  it  is  due  to  the  white  blood  cells  circulating  in  the  blood, 
and  which  gain  entrance  into  the  vessel  from  the  vasa  vasorum,  or 
by  cells  which  originate  outside  of  the  vessel  walls,  and  by  permeat- 
ing them  enter  the  lumen  of  the  vessel."  Billroth,  after  speculating 
on  the  origin  of  the  white  blood-corpuscles,   says  that  they  may 

1  Ueber  die  Vernarbung  von  Arterien  nach  Unterbindungen  u.  Verwan- 
dungeu.     Deutsche  Zeitschr.  f.  Chir.  ix. 

2  Handbuch  der  allgemeinen  Pathologie,  Leipzig,  187(>. 


150  EXPERIMENTAL  SURGERY. 

spring  from  connective-tissue  or  a  protoplasm  analogous  to  connec- 
tive-tissue, and  he  believes  that  they  may  traverse  the  living  walls 
of  vessels,  as  he  has  performed  Bubnoff's  experiment  successfully  on 
the  carotid  artery  of  a  dog. 

One  of  the  strongest  arguments  in  favor  of  the  tissue  producing 
function  of  the  wandering  blood-corpuscles  is  advanced  by  Ziegler.1 
His  experiments  consisted  in  introducing,  under  antiseptic  precau- 
tions, into  the  living  tissues  of  animals,  two  glass  plates  with  a 
capillary  space  between  them.  On  examining  the  specimens  at 
different  intervals  of  time  he  found  the  space  between  the  glass 
plates  at  first  filled  with  white  blood-corpuscles,  which  were  subse- 
quently transformed  into  connective  tissue  and  blood-vessels.  The 
results  of  these  experiments  have  made  Ziegler  an  ardent  advocate 
of  the  doctrine  that  the  wandering  corpuscle  is  the  principal  tissue- 
producing  element  in  all  regenerative  and  pathological  formations. 

Every  one  must  admit  that  these  experiments  are  both  ingen- 
ious and  beautiful,  but  the  deductions  may  lead  to  erroneous 
conclusions,  as  the  experiments  do  not  preclude  the  possibility  of 
the  entrance  of  embryonal  connective-tissue  elements  from  the 
wounded  surfaces  surrounding  the  glass  plates.  In  many  instances 
the  obliterating  process  is  accomplished  in  such  a  remarkably  short 
time  that  this  theory  would  hardly  apply,  and  until  more  positive 
evidence  is  furnished  we  must  seek  for  a  more  satisfactory  expla- 
nation. 

XIX.    Formation  of  Cicatrix  from  Endothelia. 

The  majority  of  the  older  authors  who  maintained  that  direct 
and  primary  adhesion  of  the  inner  walls  of  the  vessel  takes  place 
after  ligature,  attributed  this  occurrence  to  a  plastic  exudation  upon 
the  free  surface  of  the  intima.  In  entertaining  this  idea,  they  must 
have  necessarily  assumed  that  the  tissues  of  which  the  intima  is 
composed  are  capable  of  entering  into  tissue  proliferation  subse- 
quent to  the  traumatism  inflicted  by  the  ligature.  This  doctrine 
was  annihilated  by  Virchow,  who  taught  that  the  intima  does  not 
respond  to  any  amount  of  stimulation,  and  that,  if  the  irritation  is 

1  Experimentelle    Untersuchungen     fiber    die     Herkunft    der    Tuberkel- 
elemente,  Wttrzburg,  1875. 


FORMATION   OF   CICATRIX  FROM  ENDOTHELIA.  151 

increased  to  a  certain  degree,  necrosis  of  the  intima  takes  place  as  a 
constant  and  unavoidable  result. 

For  a  long  time  it  was  claimed  that  the  intima  takes  no  active 
part  either  in  the  organization  of  the  thrombus,  or  the  process  of 
cicatrization.  The  advancement  made  in  histology  and  the  experi- 
mental investigations  which  have  characterized  the  history  of 
medicine  for  the  last  forty  years,  have  thrown  new  light  upon  the 
subject.  The  important  part  taken  by  stable  tissue  cells  in  all 
regenerative  and  pathological  changes  is  again  fully  realized  by  the 
most  competent  observers,  and  the  presence  of  inflammatory  changes 
in  the  intima  after  ligature  is  now  fully  established. 

His1  pointed  out  the  difference  between  epithelia  and  endo- 
thelia,  and  showed  that  the  latter  originate  exclusively  from  the 
mesoblast,  belonging,  therefore,  to  the  series  of  connective-tissue 
formations  possessed,  like  all  analogous  structures,  of  the  common 
property  of  being  capable  of  entering  into  tissue  proliferation.  As 
early  as  1824,  Rokitansky  taught  that  primary  union  of  the  vessel- 
walls  and  definitive  obliteration  could  take  place  independently  of 
the  formation  of  a  thrombus.  He  believed  that  the  surfaces  of  the 
intima  adhere  nearest  to  the  ligature,  and  that  the  process  of 
obliteration  proceeds  from  this  point  to  where  collateral  circulation 
is  established.  The  vessel  is  obliterated  as  it  has  no  further  physi- 
ological function  to  perform.  He  was  never  able  to  discover  any 
vessels  in  the  thrombus. 

Cohn2  was  the  first  to  assert  that  obliteration  of  a  vessel  after 
ligation  is  due  to  proliferation  of  the  endothelial  lining  of  the 
intima.  Lancereux  in  France  and  Forster  in  Germany  adopted 
his  views. 

Waldeyer,  who  is  a  firm  believer  in  the  endothelial  origin  of  the 
intra-vascular  cicatrix,  describes  the  process  of  organization  of 
the  clot  after  ligature  as  follows:  "The  intima  is  rendered  vascular 
from  the  media.  From  the  intima  loops  of  capillary  vessels  project 
into  the  thrombus  accompanied  by  an  envelope  of  delicate  spindle- 
shaped  cells  from  the  endothelial  lining,  which  constitute  the  basis 
of  the  future  connective  tissue."3 

1  Die  Haute  und  Hohlen  des  Korpers,  Basel,  1866. 
'l  Klinik  der  embolischen  Gefasskrankheiten,  Berlin,  1860. 
3  Zur  pathologieohen  Anatomie  der  Wundkrankheiten,    Virchow's    Arch, 
vol.  xi.  p.  379. 


152  EXPERIMENTAL  SURGERY. 

Thiersch1  has  studied  experimentally  the  process  of  obliteration 
in  small  vessels  in  wounds  of  the  tongue  of  the  guinea  pig.  At  the 
point  of  injury,  both  in  arteries  and  veins,  he  has  witnessed  the 
rapid  production  of  endothelial  cells  to  which  he  attributes  the  most 
important  function  in  the  organization  of  the  clot  and  the  obliter- 
ation of  the  vessel. 

Czerny2  claims  that  organization  of  the  clot  is  complete  five 
days  after  ligation.  Although  he  refers  this  process  to  the  presence 
of  white  corpuscles  which  accumulate  in  the  thrombus  and  the 
vessel -walls,  he  satisfied  himself  that  the  endothelia  at  and  near 
the  seat  of  the  ligature  multiply  with  great  rapidity. 

Baumgarten3  has  made  some  very  interesting  experiments  to 
establish  the  capacity  of  the  endothelia  for  proliferation.  He  asserts 
that  obliteration  of  a  vessel  takes  place  without  the  intervention  of 
a  thrombus,  as  when  the  column  of  blood  is  excluded  between  two 
ligatures.  He  operated  on  rabbits  by  applying  a  double  ligature, 
either  excluding  the  blood  in  the  intermediate  portion  of  the  vessel, 
or  leaving  it  between  the  ligatures.  In  both  instances  he  obtained 
prompt  obliteration  of  the  vessel. 

In  case  the  blood  was  excluded  from  the  vessel,  he  observed  a 
cellular  product  in  the  lumen  of  the  vessel  a  few  days  after  opera- 
tion; these  cells  he  believed  to  be  the  product  of  endothelial  tissue 
proliferation,  which  was  most  marked  in  the  immediate  vicinity  of 
the  ligatures.  The  modified  endothelia  are  converted  into  fibro- 
blasts (Neumann)  and  spindles  of  connective-tissue  cells.  When  a 
thrombus  was  present,  the  granulation  tissue  gradually  displaced  the 
thrombus,  and  was  finally  converted  into  vascular  connective  tissue. 
The  vascularization  always  took  place  by  vessels  from  the  vasa 
vasorum.  The  ligatures  were  tied  with  sufficient  force  to  divide  the 
two  internal  coats.  By  applying  an  irritant  to  the  outer  surface  of 
veins,  he  also  noticed  after  twenty- four  to  forty-eight  hours  prolifer- 
ation from  the  endothelial  lining  of  the  intima.  The  endothelia 
enlarged  and  assumed  a  cuboidal  shape,  showing  conclusively  that 

1  Ueber  den  Verschluss  der  Gefasse  bei  Acupressur,  Centralbl.  f.  d.  med. 
Wissensch.,  1868,  No.  50. 

2  Von  Pitha  u.  Billroth's  Handbuch  der  Chirurgie,  vol.  i.  part  ii. 

3  Ueber  die  sogenannte  Organisation  des  Thrombus,  Centralbl.  f.  d.  med. 
Wiss.,  1876,  No.  34. 


FORMATION   OF  CICATRIX  FROM  ENDOTHELIA.  153 

they  participated  in  the   inflammatory  process  which  affected  the 
entire  thickness  of  the  vein-walls. 

For  one  of  the  most  valuable  contributions  to  our  knowledge  of 
cicatrization  in  blood-vessels  after  ligature  we  are  indebted  to  Fritz 
Raab.1  His  experiments  were  made  on  dogs,  and  always  under 
antiseptic  precautions.  The  sheath  of  the  vessel  was  opened  at  two 
places  from  1  to  4  cm.  apart,  and  after  first  tying  the  proximal  liga- 
ture in  the  case  of  arteries,  and  the  distal  ligature  in  the  case  of 
veins,  the  blood  was  squeezed  out  of  the  vessel  before  tying  the 
second  ligature,  securing  thus  a  bloodless  space  between  them.  He 
cautioned  against  opening  the  sheath  extensively  for  fear  of  pro- 
ducing necrosis  in  the  intermediate  section  of  the  vessel.  As 
ligature  material,  silk  was  used,  which  was  always  cut  short.  If  the 
ligature  cut  through  or  the  wound  did  not  heal  promptly,  a  funnel- 
shaped  sinus  remained  which  led  to  the  ligature,  and  in  all  of  these 
cases  the  portion  of  the  vessel-walls  towards  the  wound  was  found 
destroyed. 

Experiment  1.  Carotid  artery;  intermediate  portion  of  vessel  between 
ligatures  2  cm.  Animal  killed  after  twelve  days.  At  seat  of  ligature,  artery, 
vein,  and  vagus  blended  in  a  spindle-shaped,  indurated  mass  of  connective 
tissue.  Vessel  between  ligatures  completely  obliterated.  Adventitia  slightly 
infiltrated  with  cells.  Media  and  intima  normal.  Endothelial  lining  changed 
into  several  layers  of  oblong  spindle-shaped  cells.  Where  surfaces  of  intima 
were  brought  into  apposition  the  lumen  was  found  obliterated.  Remnants  of 
blood-cells  were  also  found  which  had  remained  in  contact  with  inner  walls 
of  vessel.  No  vessels  in  the  endothelial  layers  except  at  the  seat  of  ligatures, 
where  intima  and  media  had  been  circularly  divided.  Silk  ligatures  not  infil- 
trated with  cells.  Under  ligatures,  fibres  of  adventitia  remained  intact. 
Proximal  coagulum  2  cm.  in  length,  between  folds  of  intima  new  endothelial 
formations. 

Experiment  2.  External  jugular  vein;  ligatures  4  cm.  apart.  Animal 
killed  on  twelfth  day.  Around  vein  some  induration.  On  distal  side,  thicken- 
ing of  vein-walls;  lumen  smaller,  containing  a  brittle  red-brown  coagulum. 
Between  ligatures,  and  two  inches  on  proximal  side,  the  vessel  was  trans- 
formed into  a  fibrous  cord.  Between  ligatures  all  coats  of  vessels  changed. 
Endothelia  multiplied  and  converted  into  spindle-shaped  cells;  between  them 
embryonal  connective-tissue  cells  and  round  cells.  No  vessels  except  close  to 
ligatures,  where  vessels  from  vasa  vasorum  had  penetrated  the  interior  of  the 
vein. 

In  commenting  on  these  cases  he  gives  his  views  concerning  the 
1  Ueber  die  Entwickelung  der  Narbe  im  Blutgefass  nach  der  Unterbindung. 


154  EXPERIMENTAL   SURGERY. 

formation  of  the  intra-vascular  cicatrix.  Slight  irritations  will  pro- 
duce remarkable  morphological  changes  in  the  endothelial  cells. 
The  walls  of  the  veins  do  not  require  a  great  amount  of  traumatism 
to  produce  these  results.  During  the  first  forty -eight  hours  after 
ligation,  marked  changes  are  observed,  which  gradually  extend  from 
points  of  ligature  to  a  certain  distance,  and  it  is  immaterial  whether 
the  vessel  contains  blood  or  whether  it  has  been  rendered  bloodless 
between  the  ligatures. 

The  first  change  in  the  endothelia  consists  in  an  enlargement  of 
the  nuclei,  which  imparts  to  the  intima  an  increased  wavy  appear- 
ance. Later,  the  nuclei  enlarge  towards  the  periphery  of  the  cells, 
displaying  the  protoplasm  so  that  the  protoplasmic  spaces  are 
diminished.  The  cells  at  this  time  assume  a  polyhedric  or  rounded 
contour.  The  naked  eye  now  detects  a  loss  of  the  glossy  surface  of 
the  intima.  Similar  changes  can  be  observed  in  the  endothelial 
lining  of  small  arteries  and  veins  in  inflamed  tissue.  The  sharp  con- 
tour of  the  nuclei  is  lost  as  soon  as  the  cells  have  attained  a  certain 
size.  The  protoplasm  is  interspersed  with  fine  molecules  which 
aggregate  at  three  or  four  points,  and  the  cell  soon  contains  from 
three  to  four  nuclei. 

Other  smaller  pyriform  or  spindle-shaped  cells  are  found  in 
immediate  contact  with  the  large  cell.  These  new  cells  originate 
from  nuclei,  and  leave  the  cell-wall  by  the  budding  process.  These 
small  or  daughter -eel  Is  are  found  in  the  lumen  of  the  vessel  on  the 
surface  of  the  endothelial  layer.  They  become  flattened,  and 
eventually  assume  the  shape  of  the  old  cells.  They  are  variable  in 
shape,  according  to  the  stage  of  development  and  locality  in  which 
they  are  found.  In  the  folds  of  the  intima  they  are  flat,  spindle- 
shaped,  and  elongated;  on  the  surface,  towards  the  lumen  of  the 
vessel,  round  or  polyhedral.  The  proliferation  takes  place  in  the 
bloodless  space  as  rapidly  as  when  a  thrombus  is  present.  The  ob- 
literating process  is  completed  earliest  near  the  ligatures.  In  veins 
the  round  cells  are  most  numerous,  while  in  the  arteries  the  flat 
spindle-shaped  cells  predominate.  As  the  connective-tissue  is  in 
closer  proximity  to  the  endothelial  cells  in  veins  than  in  arteries, 
the  proliferating  process  cannot  be  observed  so  satisfactorily  as  in  the 
latter  vessels.  For  the  same  reason  the  proliferation  of  endothelia 
begins  later  in  arteries,  and  the  process  is  accomplished  less 
rapidly.     At  first  the  proliferation  is  witnessed  in  the  folds  of  the 


FORMATION   OF   CICATRIX    FROM  ENDOTHELIA.  155 

intima  in  the  shape  of  spindle-shaped  cells  which  till  the  spaces 
between  the  elevations,  forming  bridges  from  one  fold  to  another. 

While  in  the  normal  intima  the  endothelial  lining  consists  of 
two  or  more  layers  of  cells,  in  the  inflamed  intima  an  amorphous  mass 
is  found  which  is  interspersed  with  cells  of  high  refractive  power. 
These  new  cells  accumulate  in  great  numbers,  and  finally  perforate 
the  endothelial  lining  into  the  lumen  of  the  vessel.  Heubner  found 
the  same  conditions  in  examining  specimens  of  endarteritis  in 
vessels  of  the  brain.  In  contradistinction  to  Heubner,  Raab  con- 
siders the  cells  on  the  surface  of  the  ecidothelia  as  new  productions. 
The  nutritive  supply  for  the  endothelia  is  not  derived  from  the 
blood  circulating  in  the  vessels,  but  is  derived  from  the  vasa  vasorum 
of  the  adventitia. 

The  cement  substance  liquefies  and  gradually  disappears  during 
active  proliferation.  If  the  inner  surfaces  of  a  vein  or  artery  are 
kept  in  mutual  contact,  primary  union  takes  place  at  once  by  means 
of  long  spindle-shaped  cells  which  are  the  product  of  the  endothelial 
cells.  The  space  between  the  surfaces  of  the  intima  occupied  by 
these  cells  is  finally  completely  obliterated  and  the  inner  coat  is 
transformed  into  one  tissue.  If  a  thrombus  is  present  the  em- 
bryonal cells  of  the  intima  send  prolongations  into  the  thrombus, 
which  unite  with  similar  projections  of  other  cells,  thus  forming  a 
complete  network  of  protoplasmic  strings  permeating  the  entire 
coagulum.  Upon  these  strings  new  nuclei  appear,  which  are  the 
product  of  an  aggregation  of  molecules.  The  connecting  strings 
between  the  nuclei  become  narrower  and  eventually  disappear, 
setting  free  the  nuclei  as  new  tissue  elements. 

Some  of  the  large  spindle-shaped  cells  divide  into  two  or  more 
cells.  The  spindle-shaped  cells  arrange  themselves  into  bundles 
with  spaces  between  them  which  contain  blood-corpuscles;  these 
spaces  may  easily  be  mistaken  for  new  blood-vessels.  The  endo- 
thelial product  is  not  supplied  with  vessels  until  the  tunics  partici- 
pate in  the  process,  when  vascularization  takes  place  from  the 
vasa  vasorum.  Obliteration  can  take  place  by  tissue  derived  exclu- 
sively from  the  intima,  but  all  coats  of  the  vessel  assist  in  the  process 
from  the  beginning.  The  connective  tissue  immediately  beneath 
the  swollen  endothelial  cells  is  rendered  loose  and  succulent,  the 
spaces  between  the  individual  bundles  are  widened,  and  an  occasional 
cell  is  seen  in  them.    Towards  the  periphery  of  the  vessel  the  spaces 


156  EXPERIMENTAL  SURGERY. 

between  the  elastic  tissue  fibres  are  widened  and  active  infiltration 
of  cells  is  also  witnessed  here. 

These  cells,  like  the  endothelia,  send  out  projections  in  the  form 
of  long  strings  of  protoplasm,  forming  networks  with  the  connective- 
tissue  interspaces.  The  connective-tissue  between  elastic  fibres 
proliferates.  The  connective  and  elastic  tissue  spaces  are  populated 
with  cells  of  various  shapes  and  sizes.  We  find  here  cells  in  all 
stages  of  division,  large,  round,  polygonal,  and  pyriform-shaped, 
containing  in  their  interior  from  two  to  four  smaller  cells.  Around 
the  vessels  of  the  adventitia  round  lymphoid  cells  appear  which 
infiltrate  all  the  tissues  of  the  vessel.  The  microscopical  appearances 
resemble  in  many  respects  the  picture  presented  by  the  inflamed 
tissue  in  the  cornea  or  cartilage. 

Finally  the  new  tissues  perforate  the  endothelial  layers  and 
enter  the  lumen  of  the  vessel,  and  mingle  with  the  products  of  the 
endothelial  cells,  forming  a  common  cicatricial  tissue  while  the 
elements  are  being  converted  into  connective  tissue.  Vessels  of  the 
adventitia  enter  through  the  coats  of  the  vessel  into  its  lumen,  but 
the  principal  vascular  supply  of  the  intra-vascular  tissues  is  derived 
from  vessels  which  enter  near  the  ligature  through  the  spaces  made 
by  the  circular  division  of  the  inner  coats  by  the  ligature.  The 
ligature  not  only  produces  circular  division  of  the  inner  coats,  but 
also  longitudinal  lacerations  of  the  intima.  The  extent  and  degree 
of  laceration  of  the  walls  of  the  vessel  are  in  direct  proportion  to 
the  amount  of  granulation  tissue  which  is  formed  subsequently. 

Under  the  most  favorable  circumstances  direct  union  of  the 
inner  surface  of  the  intima  takes  place  exclusively  by  endothelial 
proliferation  without  a  granulative  thrombus.  Where  this  result  is 
not  obtained  the  granulation  tissue  is  formed  first,  and  advances 
from  the  seat  of  ligature  towards  and  into  the  lumen  of  the  vessel, 
where  it  unites  with  the  endothelial  product  and  produces  the  tissue 
which  has  heretofore  been  known  as  the  organized  thrombus.  The 
granulation  tissue  is  composed  at  first  of  cells,  later  of  cells,  fibres 
and  vessels,  and  finally  the  number  of  cells  is  diminished  and  the 
connective  tissue  is  increased,  when  the  vessel  is  reduced  in  size  and 
is  ultimately  converted  into  a  string  of  connective  tissue. 

Riedel1   studied  the   process  of    cicatrization  in  blood-vessels 

1  Die  Entwickelung    der    Narbe    im    Blutgefass   nach  der  Unterbindung, 
Deutsche  Zeitschrift  fur  Chirurgie,  vol.  vi.  p.  450. 


FORMATION   OF   CICATRIX   FROM  ENDOTHELIA.  157 

experimentally  in  the  same  manner  as  the  preceding  author,  and 
arrived  at  similar  conclusions.  He  used  catgut  in  place  of  silk,  and 
dogs  and  rabbits  were  made  the  subjects  of  his  experiments.  The 
space  between  the  ligatures  was  made  bloodless  by  isolating  the 
vessel,  raising  it  from  its  bed,  and  placing  a  spatula  underneath.  In 
two  of  the  specimens  the  interior  of  the  intervening  portion  of  the 
vessel  was  found  obliterated.  One  specimen  was  obtained  nine  days, 
and  the  other  sixty-three  days  after  ligation.  In  the  first  specimen 
the  endothelial  proliferation  appeared  in  the  shape  of  spindle-shaped 
connective-tissue  cells  which  filled  only  two-thirds  of  the  lumen  of 
the  vessel.  In  the  second  specimen  the  connective  tissue  in  the 
interior  of  the  vessel  was  distinctly  fibrillated.  The  elastic  layer  of 
the  intima  had  suffered  in  many  places  a  loss  of  continuity  to  give 
passage  to  blood-vessels  from  the  media  into  the  thrombus. 

In  the  next  experiment  two  ligatures  were  applied  1  cm.  apart, 
including  a  column  of  blood.  The  animal  was  killed  on  the  ninth 
day.  In  place  of  the  white  blood- corpuscles  in  the  red  thrombus, 
large  cells  containing  from  one  to  three  nuclei  were  found;  the  cell 
contents  were  either  granular  or  round  globules  of  a  yellowish  color. 
The  identity  of  these  globular  masses  with  the  red  blood-corpuscles 
deprived  of  the  greater  part  of  their  coloring  matter  was  unmis- 
takeable.  Some  of  these  large  cells  appeared  shrunken,  with  irregular 
surfaces,  denoting  incipient  disorganization.  While  these  cells  were 
found  uniformly  present  throughout  the  intervening  portion  of  the 
vessel,  the  endothelia,  half  way  between  the  ligatures,  remained 
unchanged.  Nearer  the  ligatures  the  endothelial  layer  was  much 
thickened,  completely  filling  the  longitudinal  folds  of  the  intima.  On 
the  surface  of  the  thickened  endothelial  lining  were  thin  flat  cells, 
and  behind  these  new  endothelial  cells  were  seen  the  embryonal 
connective-tissue  cells  arranged  irregularly  with  a  variable  amount 
of  intercellular  or  cement  substance. 

In  other  transverse  sections,  through  portions  of  the  vessel 
between  the  ligatures,  delicate  processes  could  be  seen  springing 
from  the  parietal  proliferation  of  the  endothelial  layer,  penetrating 
the  thrombus,  reaching  into  the  interior  of  the  vessel  and  uniting 
with  similar  processes  from  the  opposite  side.  These  processes 
carried  with  them  a  layer  of  endothelia.  At  a  right  angle  with  these 
processes  could  be  seen  similar  structures,  thus  dividing  the  interior 
of  the  vessel  into  spaces  lined  with   endothelia.     As  the  ligatures 


158  EXPERIMENTAL  SURGERY. 

were  approached  these  spaces  grew  smaller,  containing  in  their 
interior  well  preserved  red  corpuscles  and  the  large  cells  previously- 
described.  Any  activity  on  the  part  of  the  blood-corpuscles  in  this 
process  could  be  safely  excluded,  and  cicatrization  could  be  referred 
exclusively  to  the  action  of  the  endothelial  cells. 

The  question  presented  itself:  Would  the  same  process  take 
place  in  a  thrombus  not  included  between  two  ligatures  ?  To  furnish 
a  satisfactory  answer,  a  thrombus,  twenty-seven  days  old,  in  the 
femoral  artery  of  a  dog  was  examined.  The  appearances  presented 
were  identical.  The  network  of  vessels  in  the  thrombus  communi- 
cated directly  with  the  vessels  of  the  media.  Injections  made  into 
the  lumen  of  the  vessel  sometimes  followed  processes  from  the  lining 
of  the  vessel  and  rilled  the  spaces  in  the  thrombus.  About  the  seat 
of  the  ligatures  the  external  coats  were  actively  engaged  in  aiding 
the  processes  of  cicatrization. 

The  connective  tissue  proliferates,  the  new  cells  being  directed 
in  such  manner  that  they  point  towards  the  lumen  of  the  vessel. 
They  approach  the  intima  accompanied^  by  blood-vessels,  penetrate 
the  membrana  fenestrata,  and  unite  directly  with  the  endothelial 
formations.  The  spaces  in  the  membrana  elastica  of  the  intima 
increase  in  size  as  the  ligatures  are  approached,  so  that  in  place  of 
circular  necrotic  pieces  of  tissue,  large  cicatrices  are  formed.  Liga- 
tures always  produce  necrosis  of  tissue  underneath.  A  thrombus, 
twelve  days  old,  showed  the  endothelial  proliferation  in  the  form  of 
cells  corresponding  to  the  windings  of  the  elastic  intima.  The 
membrane  projected  into  the  lumen  of  the  artery.  The  conical  end 
of  the  thrombus  was  also  covered  with  endothelial  cells. 

It  is  a  well-known  fact  that  connective  tissue  can  be  transformed 
into  endothelial  cells,  as  has  been  repeatedly  observed  in  the  forma- 
tion of  new  synovial  sacs.  A  thrombus  not  included  between  liga- 
tures receives  its  first  vascular  supply  from  the  lumen  of  the  vessel. 
When  blood  is  included  between  two  ligatures,  a  scanty  network  of 
vessels  reaches  the  lumen  of  the  vessel  from  without. 

Uhle  and  Wagner1  testify  positively  to  the  importance  of  the 
functions  of  the  endothelial  cells  and  connective  tissue  in  intra- 
vascular cicatrization  in  the  following  language:  "In  all  probability 
the  most  important  structures  in  the  process  of  organization  are  the 

1  Handbuch  der  allgem.  Pathologie.     Leipzig,  1876. 


FORMATION   OF  CICATRIX  FROM  ENDOTHELIA.  159 

endothelial  cells  and  connective  tissue  of  the  intima.  These  pro- 
liferate within  a  few  hours  after  ligation,  and  are  first  transformed 
into  spindle-shaped  cells,  and  later  into  connective  tissue  and  vessels. 
As  early  as  six  or  eight  days  after  the  formation  of  the  thrombus, 
especially  towards  its  periphery,  it  is  traversed  by  a  network  of 
young  capillary  vessels  which  increase  rapidly  for  the  next  few  days. 
During  this  time  the  fibrin  and  blood-corpuscles  disintegrate  in  the 
same  manner  as  the  so-called  dissolution  of  the  thrombus.  The 
new  vessels  in  the  thrombus  and  intima  enter  into  communication 
with  the  original  and  new  vessels  of  the  media  and  adventitia,  and 
thus  a  genuine  circulation  is  established  throughout  the  entire 
thrombus;  later  an  anastomosis  is  formed  between  the  vessels  in  the 
thrombus  and  the  lumen  of  the  vessels.  Reparative  changes  are 
initiated  at  first  in  the  immediate  vicinity  of  the  ligature.  After 
four  to  six  weeks  the  circulation  in  the  thrombus  is  completed,  when 
the  vessels  again  gradually  disappear,  the  cement  substance  grows 
firmer,  the  red  blood-corpuscles  and  fibrin,  which  still  may  remain 
are  absorbed.  At  last  only  a  minute  connective-tissue  string  remains, 
which  can  only  be  recognized  by  the  aid  of  a  microscope." 

Cornil  and  Ranvier1  have  carefully  investigated  the  part  taken 
by  the  endothelia  in  cicatrization  within  blood-vessels  after  ligature. 
The  following  is  a  summary  of  their  observations:  Within  twenty- 
four  hours  after  ligation  a  clot  forms  in  the  central  end,  which 
reaches  to  the  nearest  collateral  branch.  At  this  time  the  endothelia 
are  swollen  and  granular,  containing  a  round  nucleus  and  frequently 
several  nuclei..  On  the  following  day  the  thickening  of  the  intima 
is  well  marked,  especially  near  the  ligature.  The  thickening  of  the 
internal  coat  is  due  to  a  proliferation  of  cells  which  appear  spindle- 
shaped,  but  in  truth  are  flat.  They  resemble  endothelia  or  cells  of 
connective  tissue  swollen  by  inflammation.  On  the  eighth  day  the 
internal  coat  puts  forth  nipple-shaped  elevations,  which  are  particu- 
larly well  marked  at  the  point  of  ligation.  By  the  twelfth  to  the 
fifteenth  day  these  elevations  on  the  cardiac  side  of  the  ligature 
penetrate  into  the  blood  clot,  accompanied  by  capillary  blood-vessels 
which  run  parallel  to  the  axis  of  the  elevations. 

In  longitudinal  sections  it  is  seen  that,  at  the  point  of  implan- 
tation  of  these   projections,    the   middle   coat   of    the    artery   has 

1  A  Manual  of  Histology,  by  Shakespeare  and  Simes.     Philadelphia,  1880. 


160  EXPERIMENTAL   SURGERY. 

disappeared,  so  that  they  appear  to  spring  from  the  external  coat. 
Their  vessels  are  derived  from  the  vasa  vasorum.  The  clot  disap- 
pears before  the  new  tissue,  the  spaces  between  them  being  occupied 
by  discolored  red  blood-corpuscles,  granules,  and  a  few  white 
corpuscles,  an  appearance  which  simulates  blood- channels,  as 
described  by  O.  Weber. 

I  will  mention  a  few  recent  American  authors  who  assign  to  the 
endothelia  an  important,  if  not  essential  function  in  the  formation  of 
the  intra-vascular  cicatrix. 

Shakespeare  1  has  made  a  number  of  experiments  to  determine 
what  histological  elements  are  active  in  the  obliteration  of  vessels 
after  ligation,  and  his  views  are  summarized  in  the  following:  An 
acute  endarteritis  follows  ligation,  during  which  the  endothelia  and 
other  cellular  elements  of  the  intima  multiply  with  great  rapidity. 
The  inflammatory  changes  are  most  marked  near  the  ligature.  The 
new  cells  are  usually  flattened  and  more  or  less  endothelial  in 
appearance.  Among  these  large  endothelioid  cells  are  a  considerable 
number  of  lymphoid  cells  and  a  few  red  blood-corpuscles.  The 
cement  substance  holding  these  elements  together,  is  sometimes 
structureless,  sometimes  granular,  and  occasionally  slightly  fibrillar. 

In  a  few  days  the  walls  of  the  plastic  clot  begin  to  bud  and  put 
forth  granulations  which  encroach  upon  the  space  between  the  inner 
surface  of  the  vessel  and  the  blood  clot,  and  upon  the  blood  clot 
itself.  The  granulations  remove  the  clot  by  pressure  and  absorption. 
The  granulations  have  much  the  same  structure  as  granulation 
tissue  in  any  other  part  of  the  body.  They  are  covered  by  a  layer 
of  endothelial  cells.  The  base  of  the  granulations  rests  upon  the 
elastic  lamina  of  the  intima  which,  up  to  the  twentieth  or  twenty- 
fifth  day,  remains  unchanged,  forming  a  sharp  boundary  between 
the  middle  coat  of  the  artery  and  the  proliferation  of  the  intima. 
There  is  usually  no  indication  of  its  perforation  by  a  capillary  loop 
from  the  vasa  vasorum.  As  the  projections  of  granular  tissue 
approach  each  other,  sinuses  are  formed  in  which  the  blood  circulates 
and  supplies  capillary  vessels  which  at  this  time  are  formed  at  the 
bottom  of  the  plastic  clot.  At  the  same  time  capillary  varices  form 
in  the  embryonal  tissue  of  the  outer  coats  of  the  vessel  in  the  neigh- 
borhood and   at  the  location  of  the  ligature.     They  receive  their 

1  Cornil  and  Ranvier's  Manual  of  Histology,  p.  322. 


FORMATION   OF  CICATRIX  FROM  ENDOTHELIA.  161 

blood  from  the  vasa  vasoruin.  In  a  few  days  the  two  capillary  sys- 
tems form  a  communication  with  one  another  by  means  of  connecting 
loops  which  perforate  the  space  between  the  injured  elastic  mem- 
brane of  the  intima  at  the  point  of  ligature.  The  granulation  tissue 
undergoes  cicatrization  and  contraction,  which  obliterate  the  vessel. 

The  author  describes  at  some  length  the  laminated  structure  of 
the  thrombus,  and  it  is  evident  that  the  vascular  networks  in  the 
thrombus  were  simply  spaces  between  the  lamina,  which  were  occu- 
pied by  the  pre-existing  blood-corpuscles  in  the  thrombus,  and  that 
vascularization  took  place  exclusively  from  the  vasa  vasorum. 

Agnew1  believes  that  the  production  of  the  new  tissue  may  be 
accomplished  by  white  blood-corpuscles,  endothelia  and  migrating 
corpuscles. 

Lidell "  holds  that  the  thrombus  undergoes  organization,  but 
attributes  the  definitive  closure  to  adhesive  inflammation  of  the  inner 
and  middle  coats,  the  plastic  exudation  from  the  adventitia  giving 
additional  strength  to  the  walls  of  the  vessel.  In  speaking  of  the 
same  process  in  veins  he  says:  "Again,  veins  may,  and  often  do, 
undergo  repair  after  ligature  without  any  inflammation  whatever, 
whether  adhesive  or  otherwise,  as  Mr.  Travers  was  the  first  to  show." 

Wyeth3  takes  a  more  advanced  ground  and  regards  the  endo- 
thelia as  the  essential  element  in  effecting  definitive  obliteration.  He 
writes:  "The  permanent  occlusion  is  due  to  new-formed  tissue 
springing  from  the  normal  cells  of  the  intima." 

Heitzmann  says:  "Occlusion  of  ligated  vessels  is  due  mainly 
to  endothelial  proliferation,  and  vascularization  of  the  thrombus 
starts  in  the  inflamed  intima."4 

The  fact  that  endothelia  are  endowed  with  sufficient  vitality  to 
proliferate  new  tissue  is,  however,  not  based  alone  on  the  observa- 
tions of  practical  surgeons  and  experimental  research,  it  is  also 
supported  by  pathological  processes  which  affect  the  inner  tunics  of 
the  vessel.  Virchow,  in  his  experiments  on  embolism,  introduced 
triangular  pieces  of  rubber  into  the  right  heart  through  the  external 
jugular  vein.      After    four    weeks    he  found  the   piece   of    rubber 

1  The  Principles  and  Practice  of  Surgery,  vol.  i,  p.  155. 

2  Injuries  of  Blood-vessels,  Internat.  Encyclop.  of  Surgery,  1883,  vol.  iii. 

3  Surgical  Diseases  of  the  Vascular  System,  Internat.  Encyclop.  of  Surgery, 
vol.  iii,  p.  351. 

4  Micros.  Morphol.  of  the  Animal  Body  in  Health  and  Disease,  N.  Y.  1883. 

11 


162  EXPERIMENTAL  SURGERY. 

impacted  in  a  branch  of  the  pulmonary  artery,  encysted  in  a  vascular 
capsule  composed  of  spindle-cells  and  flat-cells,  evidently  products 
of  the  endothelial  lining. 

The  inflammatory  changes  which  occur  in  the  endothelia  of 
serous  membranes  have  been  studied  by  Rindfleisch,  Klein,  andCornil 
and  Ranvier.  Kundrat  selected  for  his  investigations  the  peri- 
toneum, Chapman  the  pericardium,  and  Albert  the  synovial  mem- 
branes. Ponfick  has  called  special  attention  to  the  rapid  changes 
which  take  place  in  the  endothelia  during  the  acute  stage  of  infec- 
tious diseases,  and  Heubner  has  assigned  to  them  a  special  suscep- 
tibility for  the  syphilitic  virus. 

Although  O.  Weber1  takes  it  for  granted  that  thrombosis  and 
organization  of  the  clot  are  the  two  essential  conditions  which  pre- 
cede and  accompany  the  definitive  obliteration  of  a  vessel,  he  states 
distinctly  that  he  has  seen  the  endothelia  repeatedly  in  a  condition 
of  so-called  cloudy  swelling,  which  would  indicate  that  he  has  wit- 
nessed the  first  stage  of  progressive  tissue  metamorphosis  in  these 
structures — the  first  stage  of  inflammation. 

Friedlander2  has  described  a  heretofore  unknown  affection  of 
the  arterial  coats  which  he  has  called  "arteritis  obliterans."  The 
affection  is  located  in  the  intima  of  arteries  of  medium  and  smallest 
calibre,  and  results  in  stenosis  and  sometimes  complete  obliteration 
of  the  vessel.  The  process  is  inaugurated  by  the  appearance  of 
numerous  round-cells  between  the  innermost  lamellae  of  the  elastic 
layer  and  the  endothelial  lining.  The  cells  increase  in  size,  inter- 
cellular substance  is  formed,  and  the  new  product  presents  all  the 
characteristic  appearances  of  granulation  tissue  with  an  abundant 
supply  of  new  vessels,  some  of  which  are  of  considerable  size.  The 
proliferation  may  be  limited  to  small  points,  or  it  may  involve  the 
entire  circumference  of  the  vessel.  The  new-formed  tissue  is  gene- 
rally converted  into  dense  connective  tissue,  seldom  undergoing 
fatty  or  calcareous  degeneration. 

A  physiological  process  very  similar  to  the  one  described  takes 
place  during  the  occlusion  of  the  ductus  arteriosus  Botali  in  the 
vessels  of  the  umbilical  cord  after  birth,  and  in  the  arteries  and  veins 
of  the  uterus  after  parturition.     Analogous  changes  are  observed  in 

1  V.  Pitha  u.  Billroth's  Handb.  d.  allg.  u.  spec.  Chir.  vol.  ii.  div.  ii.  part  i. 

2  Ueber  Arteritis  obliterans.  Centralblatt  f.  d.  med.  Wiss.  No.  4,  1876. 


FORMATION   OF  CICATRIX  FROM  ENDOTHELIA.  163 

the  small  vessels  in  tissues  which  are  the  seat  of  chronic  inflamma- 
tion. Heubner  has  described  it  as  it  occurs  in  the  vessels  of  the 
brain,  but  he  was  wrong  in  asserting  that  it  was  caused  by  the 
specific  effect  of  the  syphilitic  virus. 

Regarding  the  source  of  the  cellular  elements,  he  mentions 
three  probabilities:  1.  Either  they  are  the  product  of  the  endothelia 
of  the  intima;  2.  They  originate  from  white  blood -corpuscles  in  the 
lumen  of  the  vessel  which  must  pass  through  the  endothelial  lining 
of  the  vessel ;  3.  Or  leucocytes  from  the  vasa  vasorum.  Friedlander 
is  inclined  to  the  belief  that  they  are  derived  from  all  three  of  these 
sources. 

Winiwarter1  reports  a  case  of  spontaneous  gangrene  of  the  foot 
in  a  man  fifty-seven  years  of  age,  who  presented  no  symptoms  of 
atheromatous  degeneration  of  the  vessels.  On  submitting  the  vessels 
of  the  amputated  member  to  a  thorough  microscopical  examination, 
he  found  a  proliferation  of  endothelial  cells  of  the  intima  in  the 
arteries  and  veins,  which  had  produced  narrowing,  and,  in  some 
places,  complete  obliteration  of  their  lumen.  He  found  the  prolifera- 
tion most  active  in  small  vessels  which  are  composed  exclusively  of 
endothelia.  The  endothelia  increase  in  size  and  assume  a  cuboidal 
shape,  and  as  the  proliferation  advances  the  endothelial  lining  is 
thickened  by  additional  closely  packed  layers  of  cells. 

In  examining  transverse  sections  of  the  smallest  arteries,  he 
observed  the  following  appearances:  The  endothelial  cells  are 
arranged  in  concentric  layers;  towards  the  lumen  of  the  vessel  they 
are  spindle-shaped  and  partly  converted  into  connective  tissue.  In 
places  where  the  vessel  is  not  entirely  obliterated,  its  lumen  often 
appears  irregular  in  outline,  owing  to  the  greater  activity  of  tissue 
production  in  some  portions  of  the  inner  walls  of  the  vessel  than  in 
others.  The  media  is  also  thickened,  partly  by  the  increase  of  mus- 
cular fibres,  and  partly  by  cell  infiltration  from  the  intima.  The 
cellular  thrombus  in  the  interior  of  the  vessel  is  organized,  and  the 
cellular  elements  are  gradually  converted  into  connective  tissue 
which  completely  and  permanently  obliterates  the  vessel,  transform- 
ing it  into  a  round  string  of  connective  tissue.  In  the  interior  of  such 
strings,  deposits  of  a  homogeneous  substance  may  be  seen,  which 


1  Ueber  eine  eigenthumliche  Form  von  Endarteritis  und  Endophlebitis. 
Archiv.  f.  klinische  Chirurgie,  vol.  xxiii.  p.  206. 


164  EXPERIMENTAL  SURGERY. 

indicate  that  retrograde  metamorphosis  of  the  cellular  elements  has 
occurred  in  place  of  organization  into  connective  tissue.  The  same 
conditions  were  also  found  in  veins. 

Baumgarten '  has  found  the  vasa  vasorum  included  in  the  liga- 
ture in  ligating  large  vessels,  a  favorable  locality  to  study  this  process. 
The  inflammatory  process  begins  in  the  adventitial  structures,  and 
extends  by  continuity  to  the  endothelial  lining,  where  proliferation 
takes  place  promptly  and  with  considerable  activity.  Giant-cells 
may  originate  from  endothelia,  and,  in  case  of  very  minute  vessels, 
a  single  cell  may  block  the  calibre  of  the  vessel  completely.  The 
endothelial  cells,  in  the  course  of  time,  are  changed  into  spindle 
cells,  and  finally  into  connective  tissue.  The  round  cells  found  in 
the  media  and  adventitia  undergo  the  same  transformation. 

Cornil  and  Ranvier2  have  seen  several  times  cases  of  acute 
circumscribed  endarteritis  in  the  form  of  patches  as  an  isolated 
lesion.  Multiplication  of  the  endothelia  on  the  surface  of  the  inter- 
nal coat  is  peculiar  to  acute  endarteritis,  while  in  the  endarteritis 
preceding  atheromatous  degeneration,  the  proliferation  takes  place 
in  the  deepest  layer  of  the  intima.  Multiplication  of  cells  takes  place 
by  division  of  nuclei.  A  careful  study  of  the  new  elements  demon- 
strates that  they  spring  from  the  intima.  Peri-arteritis  always  co- 
exists. The  external  coat  produces  granulation  tissue.  In  the 
middle  coat  proliferating  elongated  cells  of  smooth  muscle  are  seen, 
while  the  elastic  fibres  are  broken  down  and  absorbed. 

As  a  last  witness  we  will  hear  Heitzmann3  concerning  the  endo- 
thelia when  subjected  to  irritation  and  in  a  condition  of  inflamma- 
tion, without  alluding  to  the  peculiar  views  on  protoplasm  enter- 
tained by  this  author.  Endothelia,  being  formations  of  living 
matter,  are  susceptible  of  undergoing  rapid  changes  under  the 
influence  of  irritation.  The  process  is  always  secondary  to  affections 
of  the  subjacent  vascular  connective  tissue.  The  inflammatory 
changes  in  this  tissue  as  in  every  other,  consist  in  an  increase  of 
tissue.  The  endothelial  cells  in  the  initial  stage  become  coarsely 
granular,  or  assume  the  "condition  of  cloudy  swelling."  The  coarse 
granutes  increase  in  size,  and  constitute  the  inflammatory  elements  in 

1  Ueber  chronische  Arteritis  u.  Endarteritis,  Archiv  f.  path.  Anatomie  a. 
Phys.,  vol.  lxxiii.  p.  90. 

2  A  Manual  of  Histology,  by  Shakespeare  and  Simes,  Phila.  1880,  p.  307. 

3  Loc.  cit. 


FORMATION   OF   CICATRIX   FROM   CONNECTIVE   TISSUE.     165 

all  stages  of  development,  reaching  the  highest  development  in  the 
nucleated  cells. 

The  endogenous  new  formation  of  elements  within  the  epithelia 
was  first  maintained  by  Remak  in  physiological,  and  afterward  by 
Buhl,  Rindfleisch,  and  others  in  pathological  conditions,  and  its 
existence  thoroughly  proved  by  L.  Oser.  In  opposition  to  the  sup- 
position that  the  corpuscles  visible  in  the  endothelia  had  immigrated 
from  without,  Oser  demonstrated  the  origin  of  inflammatory  cor- 
puscles within  the  epithelia.     Heitzmann  corroborates  this  view. 

A  sufficient  number  of  competent  and  reliable  authorities  have 
been  cited,  and  enough  has  been  said  to  prove  that  the  vascular 
endothelia,  when  subjected  to  a  sufficient  degree  of  irritation,  are 
susceptible  of  assuming  inflammatory  changes,  and  capable  of  pro- 
liferating new  tissue  elements  which,  if  not  the  only  reparative 
material,  at  least  render  essential  assistance  in  the  process  of  cica- 
trization after  ligature.  It  is  important,  however,  to  remember  that 
the  process  of  endothelial  proliferation  is  secondary  to  the  inflam- 
matory changes  which  take  place  in  the  vascular  connective  tissue. 
The  peri-arteritis  and  meso-arteritis  which  immediately  follow  liga- 
tion are  attended  by  the  formation  of  new  blood-vessels  which  pene- 
trate the  intima,  bringing  the  endothelial  lining  in  direct  contact 
with  the  circulation,  which  places  the  endothelia  under  the  same  con- 
ditions of  nutrition  and  subject  to  the  same  pathological  processes 
as  any  other  vascular  organs. 

XX.    Formation   of   Cicatrix  from  Connective  Tissue. 

The  formation  of  the  intra-vascular  cicatrix  from  connective 
tissue  has  been  frequently  mentioned  as  the  cause  of  the  definitive 
closure  of  vessels  since  the  introduction  of  the  circular  ligature  by 
Jones.  It  was  urged  that  the  division  of  the  two  inner  coats  by  the 
ligature  and  the  curling  inward  of  the  lacerated  tissues  towards  the 
lumen  of  the  vessel  would  not  only  allow  of  the  adventitia  being 
brought  in  contact,  but  would  also  create  a  wound  surface  which 
would  heal  in  the  same  manner  as  wounds  in  any  other  locality. 

The  important  function  performed  by  the  connective  tissue  in 
repairing  solutions  of  continuity  in  any  part  or  organ  is  well  estab- 
lished and  recognized  by  all  authorities.  The  connective  tissue  is 
more  widely  diffused  throughout  the  entire  body,  and  its  suscepti- 
bility to  undergo  embryonal  changes  in  a  remarkably  short  time  is 


166  EXPERIMENTAL  SURGERY. 

as  well  known  as  its  capacity  to  produce  various  types  of  tissue.  It 
is  the  tissue  which  is  invariably  present  in  all  cicatricial  formations. 
This  tissue  is  present  in  all  coats  of  the  arteries  and  veins,  it  accom- 
panies blood-vessels  wherever  they  go,  hence  it  is  only  reasonable  to 
assume  that  it  plays  an  important  part  in  the  reparative  process  in 
vessels  after  ligation. 

Kolliker  and  Eberth  claimed  that  the  connective  tissue  between 
the  endothelial  lining  and  the  elastic  layer  of  the  intima  proliferates 
and  renders  material  assistance  in  the  permanent  closure  of  vessels. 

Durante  believed  that  when  only  one  ligature  is  applied, 
obliteration  of  the  vessel  takes  place  by  proliferation  of  the  intima; 
when  the  double  ligature  is  used,  the  media  and  adventitia  assume 
this  office. 

Reinhardt,  after  declaring  that  the  thrombus  remains  passive 
after  ligature,  asserts  that  obliteration  of  the  vessel  takes  place  by  an 
exudation  or  blastema  from  the  adventitia. 

Auerbach,1  under  Koster's  directions,  studied  the  obliteration  of 
vessels  experimentally  on  dogs  and  rabbits  after  single  and  double 
ligation.  In  using  the  double  ligature  he  compared  the  results 
obtained  by  excluding  the  column  of  blood  in  the  intervening  vessel 
with  those  cases  where  blood  was  included  between  the  ligatures. 
He  ascertained  that  those  vessels  furnished  the  most  favorable  con- 
ditions for  obliteration  where  the  intervening  portion  was  moderately 
filled  with  blood. 

The  first  change  observed  in  the  coats  of  the  vessel  after  liga- 
tion was  an  inflammatory  infiltration  in  the  adventitia,  proceeding  in 
a  central  direction  toward  the  lumen  of  the  vessel.  The  acute  stage 
was  followed  by  a  chronic  granulation  process  which  was  established 
almost  exclusively  in  the  adventitia  and  intima.  The  inflammatory 
infiltration  appeared  earliest  at  the  seat  of  the  ligature  and  reached 
at  this  point  the  highest  degree  of  development.  The  intima  was 
supplied  with  vessels  from  the  adventitia.  The  definitive  oblitera- 
tion of  the  vessel  was  due  entirely  to  connective-tissue  proliferation 
from  the  intima.  The  endotbelia,  although  they  manifested  an 
attempt  at  progressive  metamorphosis,  did  not  produce  new  tissue. 
In  case  the  adventitia  was  injured  or  removed  prior  to  operation  no 
changes  occurred  in  the  two  inner  coats. 

1  Ueber  die  Obliteration  der  Arterien  nach  Ligatur.    Dissertation,  Bonn, 
1877.  Virchow  u.  Hirsch's  Jahresb.  1878,  vol.  i.  p.  233. 


FORMATION   OF  CICATRIX  FROM   CONNECTIVE   TISSUE.     167 

Roser1  asserts  that  obliteration  of  an  artery  often  takes  place 
without  a  thrombus,  and  that  the  essential  structure  in  this  process 
is  the  adventitia.  After  the  two  internal  coats  have  been  severed  by 
the  ligature,  the  external  coat  is  brought  in  contact,  and  union  takes 
place  in  the  same  manner  as  in  other  wounds.  As  a  frequent  cause 
of  secondary  haemorrhage  he  mentions  that  small  traumatic  aneur- 
isms sometimes  form  at  the  seat  of  ligature  in  the  sac  of  the 
adventitia,  which  rupture,  and  that  in  case  of  ligation  of  the  artery 
in  its  continuity,  the  tension  exerted  by  the  vessel  increases  the 
danger  of  rupture.  In  healthy  animals  occlusion  of  an  artery  takes 
place  in  a  satisfactory  manner  even  if  it  is  tied  in  the  immediate 
vicinity  of  a  large  branch.  The  same  can  be  said  of  arteries 
which  are  ligated  after  amputations.  Only  in  exceptional  cases  does 
obliteration  take  place  through  the  medium  of  a  thrombus. 

For  the  most  thorough  investigations  respecting  the  definitive 
closure  of  vessels  after  ligation  from  connective-tissue  proliferation, 
we  are  indebted  to  Tschausoflv  His  experiments  were  made  on 
dogs.  The  specimens  for  microscopic  examination  were  hardened 
in  Mueller's  fluid  for  two  or  three  weeks  and  subsequently  immersed 
for  two  to  three  days  in  absolute  alcohol,  and  finally  a  few  days  in 
turpentine,  and  for  the  purpose  of  making  sections,  they  were  incor- 
porated in  a  cylinder  composed  of  wax  and  stearin. 

He  carefully  traced  the  tissue  changes  in  specimens  from  one 
to  one  hundred  and  twenty  days  old.  In  specimens  three  days  old 
he  noticed  an  increase  in  the  size  and  number  of  the  vessels  in  the 
external  coat.  At  this  time  the  connective  tissue  of  the  intima  had 
undergone  considerable  development,  the  fibres  being  directed  trans- 
versely to  the  lumen  of  the  vessel  and  in  immediate  contact  with  the 
endothelial  lining.  In  a  thrombus  of  the  brachial  artery  obtained 
eight  days  after  ligation  he  found  in  transverse  sections,  the  vessels 
of  the  media,  adventitia,  and,  to  a  lesser  extent,  of  the  intima, 
stained  blue  from  colored  injections.  The  new  connective-tissue 
formation  of  the  media  and  intima  had  gained  entrance  at  some 
point  into  the  lumen  of  the  vessel,  reaching  as  far  as  the  center  of 
the  thrombus  at  certain  places.     In  a  specimen  of  the  brachial  artery 

1  Zur  Theorie  der  Blutstillung  u.  d.  Nachblutungen.   Archiv.  f.  klinische 
Chirurgie,  vol.  xii.  p.  223. 

2  Ueber  den  Thrombus  nach  der  Ligntur.  Arch.  f.  klin.  Chirurg. 


168  EXPERIMENTAL  SURGERY. 

nine  days  old,  the  lumen  of  the  vessel  near  the  ligature  was  found 
completely  filled  with  new  connective  tissue. 

In  a  specimen  of  the  femoral  artery  eighteen  days  old  all  the 
tissues  of  the  vessels  showed  a  beautiful  network  of  capillary  vessels 
which  were  derived  from  the  external  coat.  The  original  structures 
of  the  intima  and  media  were  at  many  points  obscured  by  the  new 
formative  tissue.  The  endothelial  layer  in  some  places  was  pre- 
served, at  some  points  indistinct,  and  at  others  completely  obscured. 
The  lumen  was  filled  with  a  compact  mass  of  organized  tissue.  In 
a  thrombus  of  the  brachial  artery  twenty  days  old  the  proliferation 
of  connective  tissue  was  seen  to  project  beyond  the  endothelial  lining 
of  the  intima.  In  a  thrombus  of  the  brachial  artery  twenty-five  days 
old  the  endothelial  lining  was  seen  to  be  almost  completely  covered 
by  new  tissue  in  some  places,  while  at  others  it  was  either  indis- 
tinctly visible  or  somewhat  thickened.  The  new  connective-tissue 
fibres  in  the  intima  and  media  were  disposed  transversely,  obliquely, 
and  longitudinally.  The  lumen  of  the  vessel  was  completely  closed 
by  new  connective  tissue,  the  most  recent  formation  corresponding 
to  the  center  of  the  vessel,  while  vascularization  increased  in  a 
peripheral  direction. 

In  a  specimen  of  the  carotid  artery  thirty-two  days  old  all 
tissues  of  the  vessel -walls  were  stained  by  the  injection  fluid.  The 
endothelial  layer  was  covered  partly  or  completely  with  organized 
exudation  material;  near  the  ligature  the  endothelial  cells  had  com- 
pletely disappeared,  and  the  fibres  of  the  intima  and  media  could  no 
longer  be  seen.  The  lumen  of  the  vessel  was  completely  obliterated. 
The  remains  of  the  thrombus  consisted  of  pigment  granules.  In  a 
specimen  of  the  femoral  artery  forty  days  old  only  the  external  coat 
was  discernible.  The  endothelial  layer  was  expanded,  infiltrating 
the  intima.  In  a  specimen  of  the  femoral  artery  fifty  days  old  the 
endothelial  layer  was  obscured  by  new  connective-tissue  fibres;  the 
lumen  near  the  ligature  was  obliterated. 

In  a  specimen  of  the  carotid  artery  sixty  days  old  the  endo- 
thelial layer  was  found  mostly  covered  with  embryonal  connective 
tissue,  and  at  some  points  somewhat  thickened.  In  a  preparation 
of  the  femoral  artery,  obtained  one  hundred  and  twenty  days  after 
operation,  the  lumen  occupied  by  a  thrombus  was  not  obliterated, 
but  near  the  ligature  the  vessel  was  completely  closed.  The  vessels 
in  the  walls  of  the  artery  were  reduced  in  size  and  number.     The 


FORMATION   OF  CICATRIX  FROM   CONNECTIVE   TISSUE.     169 

endothelial  layer  in  some  places  was  displaced  by  new  tissue,  at 
other  points  it  could  be  distinctly  seen.  The  young  connective 
tissue  in  the  lumen  of  the  vessel  was  defined  by  the  plicated  endo- 
thelial layer,  and  adhered  all  around  to  the  inner  walls  of  the  vessel. 
No  vessels  could  be  seen  in  the  intra-vascular  cicatrix. 

In  commenting  on  these  specimens,  Raab  alludes  to  the  con- 
stancy with  which  inflammatory  exudation  takes  place  at  the  seat  of 
the  operation  and  ligature.  The  thrombus  varies  in  size,  and  fre- 
quently does  not  reach  as  far  as  the  nearest  collateral  branch.  As  a 
rule,  the  central  is  larger  than  the  peripheral  thrombus.  Three  to 
four  weeks  after  ligature  adhesion  of  the  inner  walls  of  the  vessel 
takes  place  near  the  ligature  by  connective-tissue  proliferation.  The 
blood-corpuscles  in  the  thrombus  become  granular,  disintegrate,  and 
are  absorbed.  Dissolution  of  the  thrombus  commences  where  organi- 
zation of  new  tissue  begins,  that  is,  near  the  ligature  and  in  the 
peripheral  portion  of  the  clot. 

That  the  pre-existing  tissues  in  the  coats  of  the  artery  are  active 
in  the  process  of  obliteration  is  made  evident  from  the  fact  that  the 
walls  of  the  vessel  are  invariably  very  much  thickened.  Tissue  pro- 
liferation in  the  coats  of  the  vessel  could  be  observed  in  cases  where 
no  progressive  changes  could  be  recognized  in  the  thrombus.  No 
attempt  at  organization  ever  took  place  prior  to  the  fourth  day. 
Vascularization  of  the  inner  tunics  is  attended  by  an  active  con- 
nective-tissue proliferation;  the  new  tissue  advances  in  a  central 
direction  and  finally  gains  entrance  into  the  lumen  of  the  vessel. 

The  best  possible  proof  of  the  importance  of  the  vessel-walls  in 
the  process  of  obliteration  is  furnished  by  the  fact  that  tissue  pro- 
liferation takes  place  within  them,  independently  of  the  formation  of 
a  thrombus.  The  connective  tissue,  wherever  found  in  the  tunics  of 
the  vessel,  takes  part  in  the  process,  the  endothelia  and  muscular 
fibres  of  the  media  taking  no  active  part.  The  endothelial  layer  is 
perforated  by  the  new  connective  tissue,  or  is  pushed  before  it 
towards  the  center  of  the  lumen  of  the  vessel.  The  final  disposition 
of  the  endothelia  and  muscular  fibres  probably  consists  in  atrophy 
and  absorption. 

With  the  evidence  before  us  we  are  certainly  not  warranted  in 
assuming  with  Tschausoff  that  the  endothelia  are  not  susceptible  of 
tissue  proliferation  under  such  conditions  as  are  croated  by  the  Liga 
ture.    Endothelia  and  connective  tissue  have  one  common,  embryonal 


170  EXPERIMENTAL  SURGERY. 

origin,  and  their  relations  are  such  that  in  the  vessel-walls,  changes 
in  one  are  very  apt  to  extend  to  the  other.  Connective  tissue  can  be 
transformed  into  endothelia,  and  there  is  no  well-founded  reason 
why  the  reverse  should  not  occur.  Even  Tschausoff,  who  explains 
the  whole  process  of  cicatrization  from  a  standpoint  that  the  con- 
nective tissue  is  the  only  active  element,  volunteers  the  assertion 
that  on  several  occasions  he  has  seen  the  endothelial  lining  thick- 
ened, which  certainly  would  imply  tissue  increase  from  pre-existing 
cell  elements. 

After  having  excluded  fibrin  and  the  morphological  elements 
of  the  blood  within  and  without  the  walls  of  the  vessels,  as  active 
agents  in  accomplishing  definitive  obliteration  of  the  vessel  after 
ligature,  we  are  prepared  to  impute  to  the  endothelial  cells,  and  to 
the  connective  tissue  in  the  vessel-walls,  the  role  of  active  agents 
in  the  formation  of  the  intra-vascular  cicatrix.  Both  of  these  histo- 
logical elements  are  transformed  into  embryonal  tissue,  which  in 
turn  is  changed  into  mature  connective  tissue.  The  tissue  pro- 
liferation is  initiated  at  the  point  of  greatest  irritation,  the  seat  of 
traumatism,  and  in  the  vascular  adventitia;  from  these  points  it  ex- 
tends towards  and  into  the  lumen  of  the  vessel. 

This  process  of  tissue  proliferation  is  attended  by  the  formation 
of  new  vessels  from  the  vasa  vasorum,  which  permeate  all  tunics  of 
the  vessel  and  supply  the  intra-vascular  thrombus  of  embryonal 
tissue,  which  is  finally  converted  into  perfect  connective  tissue,  and 
results  in  the  definitive  closure  of  the  vessel.  After  the  function  of 
the  vessel  has  been  permanently  abolished,  all  remaining  histological 
elements  from  non-use  and  cicatricial  compression  undergo  atrophy 
and  eventually  disappear  completely  by  absorption,  leaving  only  a 
string  of  connective  tissue  to  indicate  the  extent  of  the  obliterated 
vessel.  The  vessels  in  the  cicatrix,  having  accomplished  the  pur 
pose  for  which  they  were  intended,  gradually  disappear,  an  occur- 
rence which  is  followed  by  contraction  and  atrophy  of  the  cicatrix 
itself. 

XXI.   Primary  Union  in  Blood-Vessels  after  Ligature. 

By  the  healing  of  a  wound  by  primary  union  we  understand 
rapid  repair  without  suppuration.  Used  in  this  sense  the  term 
could  be  appropriately  applied  to  almost  every  case  of  ligation  of 
vessels,  if  the  operation  were  done  under  antiseptic  precautions.    As 


PRIMARY   UNION  AFTER   LIGATURE.  171 

applied  to  vessels  after  ligature,  this  term,  however,  conveys  another 
and  still  more  significant  meaning:  it  implies  union  between  the 
inner  surfaces  of  the  lumen  of  an  arteiy  or  vein,  independently  of 
the  formation  of  a  thrombus.  The  importance  of  guarding  against 
suppuration,  and  of  securing  primary  union  of  the  wound,  have  been 
repeatedly  alluded  to  as  conditions  which  favorably  influence  the 
process  of  cicatrization  in  vessels.  All  conditions  which  impair 
normal  healthy  tissue  proliferation  at  the  seat  of  ligature  affect 
unfavorably  the  reparative  process  after  ligature.  Atheroma  of  the 
tunics  of  the  vessel,  excessive  inflammation  and  suppuration,  cannot 
fail  to  exert  a  deleterious  influence  upon  the  reparative  process  in 
the  walls  of  the  vessel  after  ligature. 

From  what  we  have  gleaned  from  the  literature  on  thrombosis, 
tissue  proliferation,  and  regeneration,  we  are  justified  in  asserting 
that  obliteration  of  a  vessel  after  ligature  takes  place  promptly  with- 
out a  thrombus,  and  further  that  the  only  function  of  the  thrombus 
is  to  furnish  a  favorable  soil  for  the  development  and  maturation  of 
the  tissue  which  grows  into  the  lumen  of  the  vessel  from  the  stable 
cells  of  its  tunics,  and  which  is  destined  to  furnish  the  cicatricial 
tissue  for  permanent  obliteration.  Experiment  and  clinical  obser- 
vation furnish  abundant  evidence  that  closure  of  vessels  frequently 
does  take  place  without  thrombus  formation.  The  many  cases  of 
successful  lateral  ligation  of  large  veins  with  preservation  of  the 
lumen  of  the  vessel  also  speak  in  favor  of  primaiy  union.  H. 
Braun1  collected  fifteen  cases  of  lateral  ligature  of  veins,  of  which 
number,  ten  proved  successful. 

Eliminating  the  thrombus  as  an  active  agent  in  the  obliterating 
process,  we  can  say  that  union  between  the  tissues  which  are  brought 
in  contact  by  the  ligature  takes  place  by  tissue  proliferation  from  the 
walls  of  the  vessel  itself.  In  its  true  sense  direct  or  primary  union 
never  takes  place,  as  in  all  instances  closure  is  effected  by  granu- 
lation and  cicatrization.  In  case  the  inner  tunics  are  severed  by 
the  ligature,  the  lacerated  surfaces  are  brought  in  contact  with  the 
adventitia,  and  repair  takes  place  as  in  other  tissues  which  are  largely 
composed  of  connective  tissue,  the  process  extending  from  both 
sides  of  the  ligature,  where  endothelia  assist  in  the  process  of 
cicatrization.     If,  on  the  other  hand,  the  continuity  of  the  vessel  is 

1  Verhiindlungen  der  DeutKchen  Gesellsch.  fur  Chirurgie,  1882. 


172  EXPERIMENTAL  SURGERY. 

not  destroyed  by  the  ligature,  and  the  intima  is  brought  in  contact, 
the  connective-tissue  proliferation  perforates  the  endothelial  lining, 
and  the  elements  of  the  latter  join  in  the  reparative  process  by  being 
converted  into  embryonal  and  subsequently  into  connective  tissue. 
The  first  inflammatory  changes  in  endothelia  are  observed  near  the 
seat  of  -the  ligature  about  the  third  day,  and  the  use  of  the  tem- 
porary ligature  has  demonstrated  that  in  arteries  about  the  size  of 
the  radial,  even  when  the  internal  coats  are  ruptured,  three  or  four 
days  are  necessary  for  sufficiently  firm  adhesions  to  take  place  to 
resist  the  intra-arterial  pressure. 

While  vascular  tissues  may  unite  firmly  after  twenty-four  to 
forty-eight  hours,  as  in  wounds  about  the  face  and  scalp,  it  requires 
from  four  to  twelve  days  for  the  tissues  of  the  vessel-walls  to  unite 
with  the  same  degree  of  firmness.  In  the  inner  tunics  of  the  vessels 
vascularization  from  the  vasa  vasorum  must  take  place  before  tissue 
proliferation  can  advance  to*  the  requisite  extent. 

In  conclusion,  we  can  say  that  wounds  in  blood-vessels  inva- 
riably heal  by  granulation  and  cicatrization,  and  that  when  a  liga- 
ture is  applied  the  definitive  intra -vascular  cicatrix  is  formed  in  a 
similar  manner. 

XXII.    Experiments. 

After  many  trials  the  sheep  was  selected  as  the  subject  of  most 
of  the  experiments,  as  it  was  found  that  this  animal  presented  the 
most  favorable  conditions  for  these  operations.  All  operations  were 
done  under  antiseptic  precautions  as  far  as  circumstances  would 
permit.  The  surface  was  shaved,  thoroughly  cleansed,  and  dis- 
infected with  a  five  per  cent,  solution  of  carbolic  acid.  Irrigation 
with  a  three  per  cent,  solution  was  used  occasionally  during  the 
operation,  and  always  before  closing  the  wound.  The  wounds  were 
invariably  completely  closed  with  a  continuous  catgut  suture,  and 
hermetically  sealed  with  salicylated  cotton  and  iodoform  collodium. 

The  vessel  sheath  was  always  opened  to  the  extent  of  one  inch 
or  more,  and  the  artery  or  vein  completely  isolated  to  the  same 
distance,  when  two  ligatures  were  placed  underneath  the  vessel. 
The  proximal  end  of  arteries  was  tied  first,  and  the  distal  end  of 
veins.  The  vessel  was  made  bloodless  by  placing  the  second  liga- 
ture in  close  contact  with  the  first  and  by  making  traction  upon  both 
ends,  and  sliding  the  loop  to  the  required  distance,  when  the  return 


EXPERIMENTS.  173 

of  blood  was  prevented  by  an  assistant  compressing  the  vessel 
between  the  thumb  and  index  finger  until  the  ligature  was  tied.  If 
any  doubt  remained  as  to  the  bloodless  nature  of  the  intervening 
space,  these  manipulations  were  repeated  before  tying  the  second 
ligature.  In  tying  the  ligatures  it  was  the  aim  not  to  injure  the 
internal  coats,  but  simply  to  approximate  the  inner  surfaces  of  the 
intima  so  as  to  effect  provisional  closure  of  the  vessel.  The  ligatures 
were  usually  applied  about  half  an  inch  to  an  inch  apart.  With  the 
exception  of  the  temporary,  all  ligatures  were  cut  short.  In  removing 
the  temporary  ligatures  the  collodium  dressing  and  suture  were 
removed,  and  the  vessel  drawn  towards  the  surface  of  the  wound  by 
making  gentle  traction  on  the  ligature  ends,  when  the  loop  of  the 
ligature  was  carefully  cut  with  small  curved  scissors.  After  the 
necessary  examination  the  wound  was  irrigated,  closed  and  dressed 
in  the  same  manner  as  before.  As  an  anaesthetic,  ether,  chloroform, 
or  bromide  of  ethyl  were  used.  The  anaesthesia  produced  by  the 
last  was  always  of  very  short  duration,  while  ether  appeared  to  offer 
the  greatest  immunity  against  accidents. 

The  illustrations  are  of  natural  size,  and  represent  the  whole 
specimen  as  removed  from  the  animal,  and  a  cross  section  through 
the  middle  of  the  intervening  portion.  The  two  perpendicular  lines 
at  the  extremities  of  the  specimen  show  the  location  of  the  ligature, 
while  the  middle  line  denotes  the  place  of  the  cross-section.  I  desire, 
in  this  place,  to  express  my  gratitude  to  my  friend  Dr.  H.  M.  Brown, 
of  Milwaukee,  for  the  valuable  aid  rendered  in  preparing  the  illus- 
trations for  this  article. 

Double  Ligation  of  Arteries. 

Experiment  1.  Right  common  carotid  artery  ligated  with  medium-sized 
catgut.  Animal  died  from  the  effects  of  the  anaesthetic  six  hours  after  opera- 
tion. Proximal  thrombus  two  inches  in  length;  non-adherent.  Minute  distal 
thrombus  in  the  folds  of  the  intima.  Inner  coats  of  the  vessel  not  injured  by 
the  ligatures.     No  appreciable  changes  in  walls  of  vessel. 

Experiment  2.  Left  common  femoral  artery  ligated  with  coarse  catgut, 
the  distal  ligature  immediately  above  the  profunda.  Animal  killed  twenty- 
four  hours  after  operation.  Proximal  thrombus,  none.  Minute  distal  throm- 
bus. Loop  of  ligature  covered  by  swollen  adventitia.  Lumen  of  profunda 
not  closed  by  thrombus. 

Experiment  3.  Right  common  iliac  artery  ligated  with  braided  silk. 
Distal  ligature  immediately  above  bifurcation.    Animal  killed  three  days  after 


174  EXPERIMENTAL  SURGERY. 

operation.  Proximal  thrombus,  none.  Minute  mural  thrombus  in  external 
iliac  artery.  No  thrombus  in  internal  iliac  artery.  On  removing  proximal 
ligature  vessel  was  found  closed  beneath  it,  while  the  intermediate  portion  of 
vessel  remained  pervious.     Loop  of  ligature  covered  by  granulation  tissue. 

Experiment  4.  Right  femoral  artery  tied  with  coarse  catgut.  Animal 
killed  seven  days  after  operation.  Proximal  thrombus  extending  to  next 
collateral  branch,  three-fourths  of  an  inch  above  the  ligature;  non-adherent, 
and  only  partly  filling  the  lumen  of  vessel.  Distal  thrombus  minute.  Inter- 
vening portion  of  vessel  filled  with  an  adherent  mass  of  granulation  tissue. 
Ligatures  softened  and  covered  by  granulation  tissue.  On  removing  central 
ligature,  lumen  of  vessel  was  found  to  be  completely  and  firmly  obliterated  by 
direct  adhesion  between  the  surfaces  of  the  intima  (Fig.  1). 

Fig.  1. 


Experiment  5.  Right  femoral  artery  ligated  with  medium-sized  catgut; 
proximal  ligature  immediately  below  the  profunda.  Animal  killed  eight  days 
after  operation.  Proximal  thrombus  about  one  inch  in  length,  small,  non- 
adherent, and  not  extending  into  the  profunda,  this  vessel  remaining  pervious. 
Filiform  peripheral  thrombus.  Intervening  portion  patent  and  adherent  to 
surrounding  tissues.  Ligatures  almost  completely  encysted;  vessel  under 
proximal  ligature  obliterated. 

Experiment  6.  Right  femoral  artery  ligated  with  coarse  braided  silk. 
Animal  killed  ten  days  after  operation.  Small  globular  proximal  thrombus. 
No  peripheral  thrombus.  Intervening  portion  and  ligatures  inclosed  by  a 
fibrous  capsule.  Underneath  distal  ligature  vessel  walls  adherent.  Interven- 
ing portion  on  the  side  corresponding  to  the  external  surface  covered  by  a 
thick  layer  of  granulation  tissue. 

Experiment  7.  Left  common  carotid  artery  ligated  with  silkwormgut 
ligature.  Animal  killed  eleven  days  after  operation.  Proximal  thrombus 
three  inches  in  length;  one  circumscribed  mural  adhesion.  Distal  thrombus, 
none.  Ligatures  completely  encysted  in  a  spindle-shaped,  fibrous  capsule 
inclosing  the  intervening  portion.  Circular  intravascular  cicatrix  underneath 
the  peripheral  ligature.  Intervening  portion  patent.  The  inner  tunics  were 
not  ruptured. 


EXPERIMENTS.  175 

Experiment  8.  Right  carotid  artery  ligated  with  coarse  catgut.  Animal 
killed  twelve  days  after  operation.  Ligatures  and  intervening  portion  sur- 
rounded by  a  fibrous  capsule.  Proximal  thrombus  conical,  and  nearly  one 
inch  in  length.  Circumscribed  points  of  adhesion  near  ligature.  No  periph- 
eral clot.  Circular  cicatrix  closing  the  vessel  completely  and  firmly  under- 
neath the  distal  ligature.     Intervening  portion  patent. 

Experiment  9.  Right  femoral  artery  ligated  with  medium-sized  silk  liga- 
tures. Animal  killed  thirteen  days  after  operation.  A  large  abscess  commu- 
nicated with  the  seat  of  the  operation,  the  walls  of  the  abscess  surrounding 
both  ends  of  the  vessel.  The  intervening  portion  was  much  shrunken  and 
completely  necrosed  and  separated.  Both  ends  of  artery  firmly  closed.  The 
proximal  end  contained  a  very  small  thrombus.  The  cicatricial  tissue  sur- 
rounding the  artery  had  drawn  the  ends  together  so  as  to  make  it  appear  as 
though  the  artery  had  suffered  no  loss  of  continuity. 

Experiment  10.  Left  carotid  artery  tied  with  coarse  catgut.  Animal 
killed  fourteen  days  after  operation.  No  thrombus.  Ligatures  and  interven- 
ing portion  surrounded  by  a  firm,  fibrous  capsule.  Ligatures  completely 
encysted,  but  remained  quite  firm.  A  firm,  circular  cicatrix  completely 
obliterated  the  artery  underneath  the  proximal  ligature.  Inner  coats  not 
injured.  Walls  of  intervening  portion  much  thickened,  and  its  lumen  near 
distal  ligature  much  contracted. 

Experiment  11.  Right  carotid  artery  tied  with  coarse  catgut.  Animal 
killed  fifteen  days  after  operation.  Proximal  thrombus  nearly  three  lines  in 
length,  almost  filling  the  lumen  of  the  vessel,  but  non-adherent.  No  distal 
thrombus.  Ligatures  and  intervening  portion  of  vessel  completely  encysted. 
Size  of  catgut  unchanged.  Inner  tunics  not  injured.  Obliterating  circular 
cicatrix  underneath  distal  ligature.  Lumen  of  intervening  portion  dimin- 
ished in  size,  and  its  walls  thickened. 

Experiment  12.  Left  carotid  artery  ligated  with  fine  silk.  Animal  killed 
eighteen  days  after  operation.  Small  proximal  thrombus.  No  distal  thrombus. 
The  intervening  portion  and  ligature  completely  encysted.  Lumen  of  vessel 
immediately  above  the  distal  ligature  closed  by  a  fine  cicatrix.  Lumen  of  the 
intervening  portion  reduced  in  size.  Folds  of  intima  filled  with  granulation 
tissue. 

Experiment  13.  Subcutaneous  artery  of  thigh  of  sheep  ligated  with 
medium-sized  catgut.  Sheep  killed  twenty-one  days  after  operation.  No 
thrombi.  Ligatures  and  invervening  portion  surrounded  by  spindle  shaped 
mass  of  connective  tissue.  Lumen  of  intervening  portion  of  vessel  completely 
obliterated  (Fig.  2). 

Experiment  14.  Right  common  carotid  artery  ligated  with  fine  catgut. 
Animal  killed  twenty-one  days  after  operation.  No  thrombus.  Intervening 
portion,  ligatures,  and  pneumogastric  nerve  surrounded  by  a  firm  capsule  of 
connective  tissue.  Lumen  of  intervening  portion  contracted  and  filled  with 
granulation  tissue,  nearer  to  proximal  ligature.  Only  the  knot  of  the  periph- 
eral ligature  remained.     Firm  union  underneath  the  ligature. 


176 


EXPERIMENTAL  SURGERY. 


Experiment  15.  Left  carotid  artery  tied  with  silkwormgut  ligature.  Animal 
killed  twenty-five  days  after  operation.  No  thrombus.  Ligature  unchanged 
and  encysted.  Coats  of  intervening  portion  of  vessel  thickened.  Circular 
cicatrix  underneath  the  proximal  ligature,  which  had  cut  through  the  greater 
portion  of  the  vessel-walls.  Intervening  portion  permeable.  Intima  presented 
a  roughened  appearance. 

Fig.  2. 


Experiment  15a.  Right  femoral  artery  tied  with  fine  silk.  Animal  killed 
thirty-five  days  after  operation.  No  thrombus.  Ligatures  encysted.  A  firm, 
fibrous  mass  between  ligatures,  in  which  the  lumen  of  the  artery,  much  reduced 
in  size  and  nearly  obliterated,  could  be  identified.  Vessel  pervious  up  to 
points  of  ligation  (Fig.  3). 

Fig.  3. 


Experiment  16.  Right  carotid  artery.  Catgut  ligature.  Animal  killed 
after  thirty-nine  days.  No  thrombus.  Ligatures  encysted.  Knots  distinctly 
visible.     Artery   obliterated   one-half    inch    above   the   peripheral    ligature. 

Fig.  4. 


Below,  vessel  pervious  to  near  ligature.  Transverse  section  between  ligatures 
showed  a  mass  of  connective  tissue  in  which  the  obliterated  artery  could  be 
distinctly  seen  (Fig.  4). 


EXPERIMENTS. 


177 


Experiment  IT.  'Right  femoral  artery  ligated  with  coarse  silk.  Animal 
killed  forty  days  after  operation.  No  thrombus.  Ligatures  encysted.  Artery 
on  either  side  of  ligatures  obliterated  to  a  distance  of  one-sixth  of  an  inch. 
Section  between  ligatures  revealed  the  vessel  in  a  mass  of  cicatricial  tissue, 
somewhat  reduced  in  size,  its  lumen  filled  with  a  mass  of  organized  tissue 
(Fig.  5). 

Fig.  5. 


Experiment  18.  Left  femoral  artery  tied  with  coarse  braided  silk.  Distal 
ligature  just  above  profunda.  Animal  killed  fifty  days  after  operation.  No 
thrombus.  Ligatures  encysted.  On  the  proximal  ends,  the  artery  was  oblit- 
erated to  a  distance  of  one-eighth  of  an  inch  above  ligature.  Intervening 
portion  converted  into  a  solid  string  of  connective  tissue  in  which  the  remains 
of  the  artery  could  still  be  recognized  (Fig.  6). 

Fig.  6. 


Experiment  19.  Right  femoral  artery.  Medium-sized  catgut.  Animal  killed 
after  fifty-two  days.  No  thrombus.  Artery  pervious  to  ligatures.  No  traces 
of  the  ligatures  could  be  found.  Intervening  portion  of  vessel  and  vagus  sur- 
rounded by  a  spindle-shaped  mass  of  connective  tissue  in  which  no  distinct 
traces  of  the  vessel  could  be  found  (Fig.  7). 

Experiment  20.  Right  femoral  artery.  Silkwormgut  ligature.  Animal 
killed  fifty-five  days  after  operation.  No  thrombus.  On  proximal  side  vessel 
obliterated  to  a  distance  of  one-third  of  an  inch;  below,  three-fourths  of  an 
inch  from  the  ligature.  Ligatures  had  apparently  cut  through  the  vessel,  and 
were  completely  encysted.  Intervening  portion  surrounded  by  a  large  mass 
of  connective  tissue  in  which  the  closed  lumen  of  the  vessel  could  plainly  be 
seen. 

Experiment  21.  Right  femoral  artery.  Medium-sized  silk,  distal  ligature 
j  t i  —  t  above  profunda.  Animal  killed  after  sixty-eight  days.  Profunda  con- 
12 


178 


EXPERIMENTAL  SURGERY. 


verted  into  a  fibrous  cord.  In  the  deep  femoral,  remnants  of  a  thrombus 
about  one-half  an  inch  in  length.  Vessel  obliterated  to  some  distance. 
Ligatures  cut  through.  One  of  them  imbedded  in  a  mass  of  cicatricial  tissue 
in  which  the  intervening  portion  of  the  vessel  could  not  be  recognized.  A 
small  abscess  communicated  with  the  seat  of  the  operation,  through  which  one 
of  the  ligatures  must  have  escaped. 

Fig.  7. 


Experiment  22.  Left  carotid  artery  of  goat  tied  with  catgut.  Animal 
killed  after  eighty  days.  Proximal  end  of  vessel  obliterated  to  within  the  next 
collateral  branch,  one-third  of  an  inch  below  ligature.  Distal  portion  of  artery 
obliterated  to  same  extent,  to  within  one-half  an  inch  of  its  bifurcation. 
Ligatures  had  completely  disappeared,  and  intervening  portion  was  converted 
into  a  solid  string  of  connective  tissue  (Fig.  8). 

Fig.  8. 


Experiment  23.  Right  femoral  artery  of  goat  tied  with  silk.  Animal 
killed  after  ninety  days.  Artery  pervious  to  within  one-half  an  inch  on 
each  side  of  the  ligatures.  Ligatures  had  probably  cut  through  the  vessel,  and 
were  completely  encysted.  Intervening  portion  of  vessel  transformed  into  a 
solid  mass  of  connective  tissue  about  the  size  of  the  vessel. 

Double  Temporary  Ligation  of  Arteries. 

Experiment  24.  Right  common  carotid  artery  of  goat  tied  with  coarse 
catgut;  removed  twenty-five  hours  after  operation.  Animal  killed  ten  days 
after  ligation.  At  the  time  the  ligatures  were  removed  the  circulation  in  the 
vessel  was  interrupted.  On  examination  the  artery  and  the  vagus  were  found 
surrounded  by  a  copious  mass  of   cicatricial  tissue.     Interiorly,  the  vessel 


EXPERIMENTS.  179 

corresponding  to  the  seat  of  the  ligatures  was  filled  and  occluded  by  a  small 
white  thrombus  projecting  into  the  distal  portion  of  the  vessel.  Cicatricial 
tissue  in  lumen  continuous  with  the  para-vascular  connective  tissue. 

Experiment  25.  Left  femoral  artery  of  goat.  Coarse  catgut.  Removal 
twenty-four  hours  after  operation.  Animal  killed  nine  days  after  ligation. 
On  removal  of  the  ligatures  circulation  not  interrupted.  Ligated  portion  of 
vessel  considerably  smaller.  Lumen  not  obliterated.  Inner  walls  of  vessel  at 
the  seat  of  operation  studded  with  minute  patches  of  exudation  material,  the 
result  of  recent  endarteritis. 

Experiment  26.  Left  carotid  artery.  Coarse  catgut;  removed  forty-eight 
hours  after  operation.  Animal  killed  ten  days  after  ligation.  On  removal  of 
ligatures,  circulation  in  vessel  not  interrupted.  An  abscess  with  thick  walls 
communicated  with  the  vessel.  The  vessel  surrounded  by  a  thick  fibrous  cap- 
sule. No  thrombus.  Lumen  of  vessel  between  seat  of  ligatures  narrowed  by 
a  copious  plastic  exudation  on  that  part  of  the  vessel  which  was  in  immediate 
contact  with  the  abscess. 

Experiment  27.  Left  carotid  artery.  Silk  ligature;  removed  forty-eight 
hours  after  operation.  Animal  killed  fourteen  days  after  operation.  Circula- 
tion not  interrupted.     Post-mortem  appearances  the  same  as  in  25. 

Experiment  28.  Left  carotid  artery.  Silk  ligature;  removed  seventy-two 
hours  after  operation.  Animal  killed  thirty-five  days  after  operation.  Circu- 
lation, on  removal  of  ligatures,  interrupted.  Proximal  clot  one  and  one-third 
inches  in  length  with  circumscribed  points  of  adhesion.  Distal  clot,  none.  At 
seat  of  operation  vessel  very  much  contracted.  Lumen  filled  with  remnants 
of  a  small  clot  and  granulation  tissue. 

Experiment  29.  Left  carotid  artery.  Silk  ligature;  removed  after 
seventy-two  hours.  Animal  killed  thirty-five  days  after  operation.  Circulation 
interrupted.  Suppuration  followed  the  removal  of  the  ligatures.  Proximal 
thrombus  about  two  lines  in  length.  Coats  of  vessel  very  much  thickened. 
Thrombus  adherent  by  plastic  exudation  from  inner  vessel-walls.  Distal 
thrombus  very  minute.  Intervening  portion  separated  at  one  end,  projecting 
into  the  abscess  cavity.  Both  ends  of  the  artery  permanently  obliterated, 
united,  and  brought  into  close  approximation  by  a  mass  of  cicatricial  tissue. 

Experiment  30.  Right  carotid  artery.  Silk  ligature;  removed  seventy- 
two  hours  after  operation.  Animal  killed  twenty-eight  days  after  ligation. 
Removal  of  ligatures  followed  by  suppuration.  No  thrombi.  Both  ends  of 
the  vessel  permanently  obliterated  and  brought  into  close  contact  by  a  mass 
of  cicatricial  tissue  in  which  no  trace  of  the  intervening  portion  could  be 
found.  Ligated  portion  of  vessel  had  probably  sloughed,  and  escaped  with 
the  contents  of  the  abscess  which  communicated  with  the  seat  of  the  operation. 

Experiment  31.  Right  common  carotid  artery,  near  subclavian.  Coarse 
catgut.  Ligatures  removed  six  days  after  ligation.  Animal  killed  sixteen 
days  after  operation.  Circulation  completely  arrested  on  removal  of  ligatures. 
No  thrombi.  Vessel,  at  seat  of  ligatures,  surrounded  by  spindle-shaped  mass 
of    connective  tissue,  in  a  transverse  section  of  which  the  artery  could  bo 


180 


EXPERIMENTAL  SURGERY. 


readily  identified,  its  lumen  being  filled  with    embryonal   connective   tissue 
(Fig.  9). 

Fig.  9. 


Experiment  32.  Left  common  carotid  artery.  Coarse  catgut.  Ligatures 
removed  six  days  after  operation.  Animal  killed  fourteen  days  after  ligation. 
On  removing  distal  ligature  vessel  gave  away.  No  haemorrhage.  Distal  end 
closed  by  a  narrow  cicatrix.  Very  minute  thrombus.  Thrombus  in  proximal 
end  two  lines  in  length;  firmly  adherent.  At  point  of  proximal  ligature 
narrow  circular  cicatrix.  Intervening  portion  of  vessel  separated  at  one  end. 
Not  necrosed.  Both  ends  of  vessel  connected  by  a  strong  bridge  of  connec- 
tive tissue. 

Double  Ligation  of  Veins. 

Experiment  33.  Right  jugular  vein.  Catgut  ligature.  Animal  killed  six 
hours  after  operation.  Minute  peripheral  thrombus.  Increased  vascularity 
of  adventitia. 

Experiment  34.  Left  femoral  vein.  Catgut  ligature.  Animal  killed  after 
twenty-four  hours.  Filiform  distal  thrombus;  none  on  the  proximal  side. 
Intervening  portion  completely  empty,  and  slightly  adherent  to  surrounding 
tissues. 

Experiment  35.  Right  femoral  vein.  Coarse  catgut  ligature.  Animal 
killed  after  three  days.  Small  distal  thrombus.  Intervening  portion  adherent 
to  surrounding  tissues,  containing  in  its  interior  a  small  granulation  thrombus. 

Experiment  36.  Right  jugular  vein.  Coarse  catgut  ligature.  Animal 
killed  after  five  days.  Minute  distal  thrombus  in  folds  of  intima.  On  remov- 
ing proximal  ligature  the  inner  surfaces  of  intima  were  found  firmly  adherent, 
evidently  by  direct  union. 

Experiment  37.  Right  femoral  vein.  Coarse  silk  ligature.  Animal  killed 
after  seven  days.  Suppuration  after  operation.  Minute  peripheral  clot. 
Ligatures  encysted.  Intervening  portion  partially  destroyed  by  suppuration. 
Ends  of  vessel  united  by  a  bridge  of  connective  tissue.  Vessel  underneath 
the  ligatures  obliterated. 

Experiment  3$.  Right  jugular  vein.  Silk  ligature.  Animal  killed  after 
nine   days.     Suppuration   followed   the   operation.     Abscess   communicated 


EXPERIMENTS. 


181 


directly  with  the  intervening  portion  of  the  vessel  which  had  nearly  separated. 
Small  truncated  distal  thrombus,  non-adherent.  Ends  of  vessel  firmly  closed 
and  united  by  a  strong  bridge  of  connective  tissue. 

Experiment  39.  Right  jugular  vein.  Medium-sized  silk  ligature.  Animal 
killed  after  twelve  days.  Minute  adherent  distal  thrombus.  Ligatures  encyst- 
ed. Intervening  portion  surrounded  by  a  capsule  of  connective  tissue.  On 
transverse  section  the  star-shaped  lumen  of  vessel  was  discernible,  firmly 
closed  by  young  connective  tissue  (Fig.  10). 

Fig.  10. 


Experiment  40.  Left  jugular  vein.  Silk  ligature.  Animal  killed  after 
fourteen  days.  No  thrombi.  Ligatures  encysted.  In  removing  the  proximal 
ligature  firm  adhesions  between  folds  of  intima.  Intervening  portion  empty, 
and  adherent  to  surrounding  tissues. 

Experiment  41.  Right  jugular  vein.  Horse-hair  ligatures.  Animal  killed 
after  twenty-one  days.  No  thrombi.  Ligatures  not  encysted,  loose  upon  the 
remaining  parts  of  the  intervening  portion.  Ends  of  vessel  closed  by  very 
narrow  cicatrix. 

Experiment  42.  Right  jugular  vein.  Catgut  ligature.  Animal  killed 
after  thirty-seven  days.  Ligature  encysted.  Vessel  obliterated  to  a  distance 
half  an  inch  from  ligatures  on  both  sides.  Intervening  portion  a  solid  string 
of  connective  tissue  in  which  no  traces  of  the  vessel  could  be  found  (Fig.  11). 

Fig.  11. 


Experiment  43.     Right  jugular  vein.     Coarse  silk  ligature.    Animal  killed 
aft(;r  forty-nine  days.     Vessel  pervious  to  near  ligatures.     Ligatures  encysted. 


182 


EXPERIMENTAL  SURGERY. 


Intervening  portion  surrounded  by  a  mass  of  connective  tissue  in  which  the 
obliterated  vessel  could  be  readily  identified  (Fig.  12). 

Fig.  12. 


Experiment  44.  Right  femoral  vein.  Medium-sized  silk  ligature.  Animal 
killed  after  fifty-four  days.  Vessel  pervious  to  near  ligatures.  Ligatures  had 
evidently  cut  their  way  through  the  vein  and  were  encysted  in  the  cicatrix. 
Intervening  portion  transformed  into  connective  tissue  (Fig.  13). 

Fig.  13. 


Experiment  45.  Right  jugular  vein.  Medium-sized  catgut.  Animal  killed 
after  eighty  days.  Ligatures  absorbed.  Intervening  portion  transformed 
into  connective  tissue. 

Double  Temporary  Ligation  of  Veins. 

Experiment  46.  Right  jugular  vein  of  goat.  Silk  ligature,  removed 
twenty-four  hours  after  operation.     Animal  killed  ten  days  after  operation. 

Fig.  14. 


Circulation  on  removing  ligatures  not  arrested.  Intervening  portion  con- 
tracted by  a  mass  of  intramural  and  para-vascular  cicatricial  tissue,  but 
patent.     Intima  normal  in  appearance.     An  abscess  communicated  with  the 


EXPERIMENTS. 


183 


seat  of  the  operation,  only  in  the  coats  of  the  vein  intervening  between  it  and 
the  lumen  of  the  vessel. 

Experiment  47.  Left  jugular  vein.  Silk  ligature,  removed  forty-eight 
hours  after  operation.  Animal  killed  thirtv-four  days  after  ligation.  Circula- 
tion arrested.  No  thrombi.  Intervening  portion  of  vessel  transformed  into 
a  firm  string  of  connective  tissue,  in  which  no  trace  of  the  original  structure 
could  be  recognized  (Fig.  14). 

Experiment  4S.  Right  jugular  vein.  Silk  ligature,  removed  three  days 
after  operation.  Animal  killed  twenty-seven  days  after  ligation.  Circulation 
arrested  at  seat  of  ligatures.  Peripheral  clot  narrow,  partially  adherent,  one 
inch  in  length.  At  the  seat  of  operation  about  two  lines  of  the  vessel  con- 
verted into  a  solid  string  of  connective  tissue  (Fig.  15). 

Fig.  15. 


L^ 


Experiment  49. — Left  jugular  vein.  Coarse  silk  ligature,  removed  three 
days  after  operation.  Animal  killed  forty  days  after  ligation.  Circulation 
interrupted.  No  thrombi.  Intervening  portion  converted  into  a  massive 
string  of  connective  tissue  (Fig.  16). 

Fig.  16. 


"-V1 


_J 


Experiment  50.  Left  jugular  vein.  Coarse  silk  ligature  removed  four 
days  after  operation.  Animal  killed  thirty-five  days  after  ligation.  Circula- 
tion interrupted.  A  short  truncated  peripheral  clot  adherent  at  its  base. 
Constricted  portion  Of  vessel  almost  but  not  completely  obliterated.  Folds  of 
Ultima  lillcd  with  recent  connective  tissue,  bridges  of  same  material  spanning 
the  lumen  of  the  vessel.  The  surface  of  the  intima  corresponding  to  the 
wound  covered  by  a  copious  plastic  exudation. 


184  EXPERIMENTAL  SURGERY. 

Experiment  51.  Right  jugular  vein.  Coarse  catgut  ligature,  removed 
after  six  days.  Animal  killed  fifteen  days  after  the  operation.  Suppuration 
followed  the  operation.  Circulation  arrested.  An  immense  white  peripheral 
thrombus  adherent  at  its  base.  Vessel  at  seat  of  distal  ligature  obliterated  by 
a  narrow  cicatrix.  Intervening  portion  contracted,  walls  thickened,  circum- 
scribed patches  of  exudation  underneath  the  proximal  ligature. 

Experiment  52.  Right  jugular  vein.  Coarse  catgut,  removed  after  six  days. 
Animal  killed  fourteen  days  after  operation.  Vein  completely  obliterated  at 
points  of  ligation.  Intervening  portion  surrounded  by  a  dense  capsule  of 
connective  tissue,  a  transverse  section  of  which  shows  the  lumen  of  the  vessel 
almost  completely  obliterated  by  plastic  exudation. 

Ligation  of  Artery  and  Vein  in  a  Horse. 

Experiment  53.  Right  carotid  artery.  Silk  ligatures.  Animal  died  eight 
days  after  operation,  death  being  caused  by  chloroform  during  the  second 
experiment.  Proximal  clot  extending  to  near  subclavian,  partly  adherent; 
distal  clot  eight  lines  in  length,  extending  beyond  nearest  collateral  branch. 
Ligatures  encysted.  Intervening  portion  surrounded  by  a  capsule  of  connec- 
tive tissue.  Walls  thickened.  Beginning  cicatrization  under  peripheral 
ligature. 

Experiment  54.  Right  jugular  vein  of  same  animal.  Coarse  silk  ligature. 
Large  distal  thrombus  completely  distending  the  vein,  and  extending  beyond 
bifurcation.  Ligatures  encysted.  Proximal  portion  of  vein  diminished  in 
size.  Intervening  portion  surrounded  by  a  capsule  of  connective  tissue. 
Underneath  proximal  ligature  firm  adhesions  between  folds  of  intima. 

XXIII.    Remarks. 

I.    Effect  of  Suppuration. 

The  deleterious  influence  of  suppuration  on  the  process  of 
cicatrization  is  well  illustrated  by  these  experiments.  In  all  cases 
where  the  wound  healed  by  primary  union,  the  isolated  portion  of 
the  vessel  became  adherent  to  the  adjacent  tissues  as  early  as  the 
second  day,  and,  after  a  few  days  more,  the  interrupted  vascular 
connections  were  restored.  In  all  cases,  with  the  exception 
of  experiments  9,  21,  37,  and  38,  where  the  wound  was  not 
reopened  for  the  purpose  of  removing  the  ligatures,  the  wound 
healed  by  primary  union,  and  cicatrization  in  the  vessel  progressed 
in  a  favorable  manner.  In  using  the  temporary  ligatures,  suppura- 
tion was  a  more  frequent  concomitant  on  account  of  the  necessary 
interference  with  the  reparative  process  in  the  wound,  and  the 
increased  difficulties  encountered  in  preventing  infection.     Suppura- 


REMARKS.— THROMBUS.  185 

tion  supervened  in  experiments  26,  29,  30,  and  50,  with  the  tem- 
porary ligature,  so  that  this  event  occurred  eight  times  out  of  fifty  - 
five,  the  whole  number  of  experiments. 

In  all  cases  where  suppuration  followed  the  operation  the 
vitality  of  the  intervening  portion  of  the  vessel  was  destroyed  in  part 
or  in  its  entirety,  and  if  a  sufficient  length  of  time  had  elapsed,  this 
portion  of  the  vessel  was  usually  found  completely  separated  and 
within  the  abscess  cavity.  Secondary  haemorrhage,  however,  was 
never  observed  as  the  result  of  suppuration,  or  sloughing  of  the 
intervening  portion,  as  the  narrow  intra-vascular  cicatrix  in  both  ends 
of  the  vessel  was  usually  supported  by  a  strong  para-vascular  ring 
of  connective  tissue  which  formed  a  part  of  the  thick  walls  of  the 
abscess.  In  all  these  cases  the  vessels  had  invariably  suffered  a  loss 
of  continuity  by  the  ligature.  These  facts  force  upon  us  the  follow- 
ing conclusions: 

1.  All  surgical  operations  on  blood-vessels  should  be  performed 
under  strict  antiseptic  precautions  for  the  purpose  of  preventing 
suppuration. 

2.  In  aseptic  wounds  the  complete  isolation  of  a  vessel  from  its 
sheath  for  a  distance  of  one  inch  is  not  followed  by  any  serious  dis- 
turbance of  nutrition  in  the  vessel-walls. 

i 

3.  Suppuration  invariably  produces  a  loss  of  continuity  of  the 
vessel  at  the  seat  of  ligature. 

4.  Inflammation  beyond  the  limits  of  the  reparative  process 
interferes  with  the  typical  formation  of  the  intra-vascular  cicatrix. 

2.     Thrombus. 

For  nearly  fifty  years  the  idea  has  prevailed,  and  to  a  great 
extent  is  still  prevalent,  that  in  applying  a  ligature  to  an  artery, 
a  thrombus  forms  on  the  proximal  side,  which  extends  to  the  nearest 
collateral  branch,  and  that  by  organization  of  the  clot  the  vessel  is 
obliterated  to  the  same  extent.  All  authors  who  attribute  definitive 
vessel  closure  to  organization  of  a  thrombus,  assert  that  the  latter 
always  precedes  cicatrization,  and  that  when  thrombus  formation 
fails  to  take  place,  permanent  obliteration  of  the  ligated  vessel  is  an 
impossibility.  I  have  shown  elsewhere  that  thrombosis  does  not 
necessarily  follow  every  case  of  ligation,  in  fact,  that  it  very  often 
fails  to  take  place,  and  yet  definitive  closure  takes  place  as  promptly 


186  EXPERIMENTAL  SURGERY. 

as  though  a  thrombus  had  formed.  Coagulation  of  the  blood  means 
necrosis  or  death  of  the  morphological  elements  of  the  clot,  and  as 
such  an  occurrence,  it  is  more  likely  to  result  from  conditions  unfa- 
vorable to  the  process  of  cicatrization.  Severe  traumatic  injuries  of 
the  vessel  and,  more  particularly,  an  infectious  inflammation  of  the 
seat  of  operation,  are  conditions  which  favor  the  formation  of  a 
thrombus. 

In  my  experiments  on  arteries  I  find  that  in  thirty-four  cases 
the  presence  of  a  proximal  thrombus  is  mentioned  thirteen  times  to 
ten  in  the  distal  portion  of  the  artery.  In  four  of  the  experiments 
it  is  noted  that  only  a  peripheral  thrombus  formed  in  seven  cases  in 
which  the  thrombus  was  found  only  on  the  proximal  side  of  the  liga- 
ture. In  most  of  the  cases  the  thrombus  was  quite  minute,  seldom 
filling  the  entire  lumen  of  the  vessel,  and  never  adherent  to  the 
inner  surface  of  the  vessel.  A  notable  exception  was  furnished  by 
the  experiment  on  a  horse,  where  an  immense  proximal  and  distal 
thrombus  formed,  filling  the  entire  lumen  of  the  vessel,  extending 
on  the  proximal  side  to  near  the  subclavian  artery,  and  on  the  periph- 
eral, to  beyond  the  bifurcation  of  the  vessel. 

In  the  specimens  derived  from  twenty-one  experiments  on  veins 
I  was  never  able  to  find  even«a  trace  of  a  thrombus  on  the  proximal 
side  of  the  ligature,  while  the  presence  of  a  distal  thrombus  was  noted 
eleven  times,  or  in  a  little  more  than  fifty  per  cent,  of  all  the  cases. 
These  experiments  furnished  the  most  favorable  opportunities  to 
study  the  process  of  cicatrization  underneath  the  proximal  ligature 
independently  of  a  thrombus,  as  the  presence  of  a  clot  was  excluded 
in  every  instance.  With  the  exception  of  the  specimen  obtained 
from  the  horse,  the  thrombi  in  veins  were  also  usually  small  in  size, 
and  seldom  adherent  over  any  considerable  surface.  Only  in  excep- 
tional cases,  both  in  arteries  and  veins,  did  the  thrombus  reach  as 
far  as  the  nearest  collateral  branch.  The  results  of  these  experi- 
ments render  it  obvious  that  the  time-worn  rule  laid  down  in  most 
of  our  text-books  on  surgery,  which  directs  the  operator  to  apply 
the  ligature  in  such  a  manner  as  to  leave  a  space  of  one  inch  or 
more  between  the  ligature  and  the  nearest  proximal  collateral  branch 
for  the  purpose  of  insuring  the  formation  of  a  thrombus,  is  wrong, 
both  in  theory  and  in  practice,  and  should  no  longer  be  followed  as 
a  guide  in  deciding  upon  the  seat  of  ligature. 


REMARKS.— LIGATURE.  187 

3.    Ligature. 

All  ligatures  were  made  strictly  aseptic,  and  in  all  instances 
where  suppuration  did  not  follow  the  operation,  they  were  encysted, 
irrespective  of  the  material  used.  Silk,  silkwormgut,  and  horsehair 
were  not  affected  by  the  granulating  process,  but  were  always  found 
unchanged  in  the  cyst.  In  all  aseptic  wounds  the  loop  of  the  liga- 
ture was  found  covered  completely  by  the  swollen  adventitia  after 
the  first  forty-eight  hours.  A  great  contrast  was  observed  between 
the  catgut  ligature  and  ligatures  made  of  material  not  susceptible  to 
absorption,  as  far  as  their  effect  on  the  vessel -walls  was  concerned. 
Catgut  applied  itself  easily  and  smoothly  to  the  exterior  of  the 
vessel-walls,  and  by  becoming  softened  and  infiltrated  with  cells,  it 
appeared  to  constitute  a  part  and  parcel  of  the  vessel-tissues  until  it 
was  replaced  by  substitution  by  a  ring  of  organized  tissue,  which 
served  as  a  material  support  to  the  vessel  until  cicatrization  was 
completed,  thus  preserving  the  continuity  of  the  vessel. 

All  the  remaining  kinds  of  ligatures  appeared  to  act  as  foreign 
bodies  as  far  as  the  vessel  tunics  were  concerned,  and  invariably 
produced  a  solution  of  continuity  after  a  sufficient  length  of  time 
had  elapsed.  They  were  usually  found  encysted  in  the  mass  of 
connective  tissue  between,  and  some  distance  from,  the  ends  of  the 
vessel.  Catgut,  on  the  other  hand,  did  not  manifest  this  tendency 
It  became  encysted,  and  underwent  absorption  in  situ.  The  earliest 
time  in  which  the  catgut  ligature  was  found  absorbed  was  twenty-one 
days,  in  experiment  14,  where  only  the  knot  remained.  In  experi- 
ment 19,  where  fifty -two  days  had  elapsed  after  the  operation,  no 
trace  of  the  ligature  could  be  found,  For  the  following  obvious 
reasons,  catgut  recommended  itself  as  the  most  desirable  and 
efficient  material: 

1.  If  catgut  is  well  prepared  it  will  resist  absorption  until 
definitive  obliteration  of  the  vessel  has  taken  place. 

2.  It  does  not  act  as  a  foreign  body,  and  does  not  destroy  the 
continuity  of  the  vessel. 

3.  It  is  completely  absorbed  and  replaced  by  organized  tissue, 
which  furnishes  an  additional  support  to  the  vessel-walls  at  the  seat 
of  cicatrization. 


188  EXPERIMENTAL  SURGERY. 

4.     Extra- Vascular  Cicatrix. 

The  first  attempt  at  obliteration  of  a  blood-vessel  after  ligature 
is  manifested  in  the  connective  tissue  of  the  adventitia  and  the 
para-vascular  connective  tissue.  As  early  as  twenty-four  hours 
after  ligation,  the  isolated  portion  of  the  vessel  has  become  adherent 
to  the  surrounding  tissues,  and  the  swollen  adventitia  overlaps  and 
covers  the  loop  of  the  ligature.  The  connective  tissue  becomes 
very  vascular,  and  undergoes  rapid  embryonal  transformation,  being 
converted  in  a  few  days  into  granulation  tissue  which  completely 
surrounds  and  embraces  the  ligatures,  the  intervening  portion,  and 
the  vessel-ends  as  the  provisional  callus  incloses  the  ends  of  a 
fractured  bone. 

This  capsule  of  connective  tissue  was  found  present  in  every 
specimen,  and  in  many  instances  was  of  remarkable  size  and  strength. 
The  thickest  portion  of  the  capsule  always  corresponded  to  the 
locality  which  had  been  subjected  to  the  greatest  amount  of 
traumatism,  that  is,  the  side  of  the  vessel  towards  the  operation 
wound.  As  soon  as  definitive  closure  of  the  vessel  had  taken  place, 
the  capsule  diminished  in  size,  until  after  a  period  of  three  months 
it  did  not  exceed  the  original  diameter  of  the  ligatured  vessel. 

The  contraction  incident  to  all  cicatricial  tissue  manifests  itself 
also  in  the  spindle-shaped  mass  of  connective  tissue  which  forms 
around  vessels  after  ligation,  and  renders  material  assistance  in  the 
process  of  obliteration  by  compressing  the  vessel,  thus  diminishing 
its  lumen.  In  all  of  our  experiments  where  union  of  the  operation 
wound  occurred  without  suppuration,  the  intervening  portion  of  the 
vessel  was  found  covered  by  granulation  tissue  as  early  as  the  third 
day,  and  the  fibrous  capsule  was  always  firmly  adherent  to  it. 
Through  the  medium  of  this  connective-tissue  capsule  the  ligated 
ends  of  the  vessel  always  formed  firm  adhesions  with  the  surround- 
ing structures,  the  artery,  vein,  and  nerve  often  being  enveloped  by 
one  common  capsule,  as  may  be  seen  well  illustrated  in  Fig.  4. 

5.     Intra-Vascular  Cicatrix. 

The  inflammatory  tissue  production  proceeds  by  continuity  from 
the  adventitia  in  a  central  direction  towards  the  lumen  of  the  vessel 
until  the  connective-tissue  proliferation  perforates  the  endothelial 
lining  of  the  intima,  an  event  which  initiates  the  formation  of  the 


REMARKS.— 1NTRA-VASCVLAR   CICATRIX.  189 

intra-vaseular  cicatrix.  Simultaneously  with  the  appearance  of  the 
granulation  process  in  the  intima  and  the  appearance  of  new  vessels 
from  the  adventitia,  the  endothelial  cells  assume  an  active  part  in 
the  process  of  cicatrization,  the  new  tissue  elements  mingling  with 
the  connective-tissue  product  and  assisting  them  in  the  formation  of 
the  internal  or  definitive  cicatrix. 

Cicatrization  begins  always  underneath  and  in  the  immediate 
vicinity  of  the  ligature.  This  fact  receives  a  satisfactory  explanation 
by  assuming  that  the  greatest  amount  of  traumatism  is  inflicted 
at  this  point,  and  that  by  interrupting  the  circulation  in  the  vasa 
vasorum  by  the  ligature,  an  active  engorgement  is  produced,  which 
accelerates  tissue  changes  and  the  formation  of  new  vessels;  at  the 
same  time  the  inner  surfaces  of  the  intima  are  here  brought  into 
accurate  and  uninterrupted  contact.  In  my  experiments  on  arteries 
three  days  was  the  shortest  period  of  time  in  which  a  narrow  firm 
cicatrix  formed  underneath  the  proximal  ligature  (Experiment  3). 

In  the  experiments  on  veins  the  condition  of  the  vessel  was 
always  examined  underneath  the  proximal  ligature,  inasmuch  as  any 
changes  in  the  tunics  and  lumen  of  the  vessel  at  this  point  had  to 
be  attributed  to  the  tissues  themselves  independently  of  a  bloodclot; 
as  the  intervening  portion  was  always  made  bloodless,  and  a  thrombus 
was  never  found  on  the  proximal  side  of  the  ligature.  In  the 
specimen  derived  from  experiment  36, 1  found  a  firm  circular  cicatrix 
underneath  the  ligature  on  the  fifth  day.  The  intervening  portion 
of  the  vessel  was  carefully  examined  at  times  ranging  from  six  hours 
to  ninety  days  after  the  operation.  This  portion  of  the  vessel, 
although  deprived  of  all  vascular  supply,  never  necrosed  unless 
suppuration  followed  the  operation.  Nutrition  was  sustained  by 
plasma  derived  from  para- vascular  tissues  until  the  interrupted  cir- 
culation in  the  vasa  vasorum  was  established,  when  the  vessel  tunics 
were  again  brought  into  a  condition  capable  of  entering  into  active 
tissue  proliferation.  In  many  of  the  specimens  it  was  noted  that 
the  walls  of  the  intervening  portion  were  found  thickened,  which 
would  certainly  indicate  that  the  tissues  did  not  remain  in  a  passive 
condition,  but  were  actively  engaged  in  the  work  of  tissue  pro 
liferation. 

The  earliest  time  at  which  granulation  tissue  was  found  upon 
the  free  surface  of  the  intima  was  seven  days  in  the  case  of  arteries 
(Experiment  4),  and  three  days  in  the  case  of  veins  (Experiment  35.) 


190  EXPERIMENTAL   SURGERY. 

The  formation  of  the  cicatrix  in  the  lumen  of  the  vessel  always 
began  near  the  ligatures,  the  material  filling  the  folds  of  the  intima 
often  forming  distinct  bridges  connecting  the  highest  points  of 
adjacent  ridges.  In  several  instances  I  observed  the  greatest  amount 
of  exudative  tissue  on  that  surface  of  the  vessel  which  was  directed 
towards  the  wound.  The  amount  of  granulation  material  in  the 
lumen  of  the  vessel  appeared  to  vary;  in  some  specimens  the  lumen 
presented  a  stellate  shape,  the  surfaces  of  the  intima  adherent  with 
a  minimum  amount  of  material  between  them  (Fig.  10),  while  in 
other  specimens  a  cylindrical  mass  of  embryonal  connective-tissue 
occupied  the  interior  of  the  vessel  (Fig.  5).  Complete  obliteration 
of  the  intervening  portion  took  place  in  the  femoral  artery  thirty- 
five  days  after  operation  (Experiment  15a),  after  thirty-nine  days  in 
the  carotid  (Experiment  16),  and  after  twelve  days  in  the  jugular 
vein  (Experiment  39). 

As  cicatrization  advances  the  original  structures  of  the  tunics 
disappear,  the  endothelia  are  transformed  into  connective  tissue,  and 
between  the.  para-vascular  and  intra-vascular  cicatrices  the  elastic 
and  muscular  tissues  undergo  degeneration  and  are  removed  by 
absorption.  The  ultimate  effects  of  the  ligature  are  obliteration  of 
the  lumen  and  conversion  of  all  the  tunics  of  the  vessel  into  a  solid 
string  of  connective-tissue  which  is  again  destined  to  undergo  various 
degrees  of  atrophy. 

6.     Temporary  Ligature. 

The  experiments  with  the  temporary  ligature  were  made  with  a 
view  to  ascertain  intra  vitam,  the  time  required  for  definitive  closure 
to  take  place  after  ligation.  In  arteries  where  the  ligatures  were 
removed  twenty-four  and  twenty-five  hours  after  ligation,  and  the 
animals  killed  on  the  tenth  and  ninth  days,  no  definitive  closure  had 
taken  place,  but  the  specimens  presented  evidences  of  arteritis  and 
endarteritis.  In  experiment  29  the  carotid  artery  was  ligated  and 
the  ligatures  were  removed  seventy-two  hours  after  operation,  when 
the  circulation  was  found  completely  interrupted;  and  the  specimen 
obtained  thirty-five  days  after  operation  showed  that  the  vessel  had 
been  completely  divided  by  one  of  the  ligatures,  but  that  both  ends 
were  permanently  obliterated.  In  experiment  31  (carotid  artery)  the 
ligatures  were  removed  after  six  days,  and  the  specimen  obtained 
sixteen  days  after  operation  showed  that  the  intervening  portion  was 


REMARKS.— INTRA-VASCULAR   CICATRIX.  191 

undergoing  definitive  obliteration,  its  contracted  lumen  being  filled 
with  a  small  granular  thrombus  (Fig.  9). 

In  the  veins  the  temporary  ligature  appeared  to  produce  its 
effects  in  a  shorter  time  and  with  a  greater  degree  of  certainty.  In 
two  experiments  on  the  jugular  vein  (experiments  47  and  48)  the 
ligatures  were  removed  after  forty-eight  hours,  and  in  both  cases 
the  circulation  was  completely  and  permanently  arrested;  and  the 
specimens  obtained  thirty-four  and  twenty-seven  days  after  opera- 
tion showed  that  the  intervening  portions  had  been  converted  into 
strings  of  connective  tissue  (Figs.  14  and  15). 

From  these  experiments  it  appears  that  in  arteries  the  size  of 
the  carotid,  at  least  three  days  are  required  for  the  cicatrix  under- 
neath the  ligature  to  become  sufficiently  firm  to  resist  the  intra- 
arterial pressure  independently  of  the  ligature,  while  in  the  jugular 
vein  the  same  object  is  accomplished  in  two  days. 

7.     Microscopical  Appearances  of  the  Recent  Intra- 
vascular Cicatrix. 

I  shall  not  attempt  to  give  a  detailed  account  of  the  micro- 
scopical appearances  of  the  different  tunics  at  different  and  successive 
stages  during  cicatrization,  but  shall  describe  briefly  the  embryonal 
tissues  which  are  found  within  the  lumen  of  the  intervening  portion 
of  the  vessel  and  its  immediate  boundaries.  These  observations 
were  made  on  transverse  sections  through  the  intervening  portion 
equidistant  from  the  ligatures.  Figure  17  represents  the  inner 
border  of  the  wall  of  the  femoral  artery  and  a  portion  of  its  lumen, 
in  a  transverse  section  of  the  specimen  obtained  from  experiment 
19,  fifty-two  days  after  operation,  and  illustrated  by  Fig.  7.  The 
open  lumen  of  a  small  vessel  can  be  seen  in  the  intima  near  its 
inner  border.  From  the  intima  projections  of  connective-tissue 
proliferation  are  seen  to  penetrate  into  the  lumen  of  the  vessel, 
pushing  before  them  the  endothelial  lining,  and  perforating  it  at 
different  points,  forming  subsequently  a  network  of  connective  tissue 
in  the  interior  of  the  vessel,  in  the  meshes  of  which  are  seen  masses 
or  nests  of  new  endothelial  cells,  also  products  of  the  pre-existing 
endothelial  elements.  At  certain  places  the  endothelial  cells  assume 
an  oval  and  spindle-shaped  form  prior  to  being  transformed  into 
connective  tissue.  Blood-vessels  from  the  intima  accompany  the 
projections  of   connective  tissue  into  the  lumen  of  the  vessel. 


192 


EXPERIMENTAL   SURGERY. 


Figure  18  represents  a  transverse  section  through  the  interven- 
ing portion  of  the  jugular  vein,  obtained  forty-nine  days  after  opera- 
tion from  experiment  43,  and  illustrated  by  Fig.  12.  It  shows  the 
intima  and  a  portion  of  the  granulation  thrombus  which  has  per- 
manently closed  the  lumen  of  the  vessel.     The  microscopical  appear- 


Vasa  vasorum. 


Partly  formed  connective 
tissue  from  endothelia. 


Proliferated 
connective 
tissue  in 
lumen. 


Endothelial  4- -_  _.\l<?® 
proliferation.         ~~  --  «^' 


Fig.  17.     Microscopical  appearances  presented  by  specimen  from  experi- 
ment 19.     Transverse  section  through  border  of  artery.     X  240. 


ances  are  almost  identical  with  the  arterial  specimen.  Both  of  these 
illustrations  furnish  the  best  possible  demonstration  of  the  manner 
in  which  the  intra-vascular  cicatrix  is  formed  from  the  connective 
tissue  and  endothelia.  The  macroscopical  and  microscopical  exami- 
nation of  the  specimens  are  alike  confirmatory  of  the  assertion  that 
the  intra-vascular  cicatrix  is  the  exclusive  product  of  connective 
tissue  and  endothelial  proliferation. 


PRACTICAL   SUGGESTIONS. 

XXIAT.     Practical  Suggestions. 


193 


The  results  of  my  own  experiments,  as  well  as  the  literature  on 
the  subject,  tend  to  prove  that  all  kinds  of  ligatures,  provided  they 
have  been  made  aseptic,  always  become  encysted  in  aseptic  wounds. 
All  ligatures,  however,  which  permanently  resist  absorption,  destroy 
the  continuity  of  the  vessel,  and  on  this  account,  instead  of  adding 


Endothelial 
proliferation 


_   Proliferation 
srj  of  connective 

^■VritasJ  tissue. 


Connective 
tissue  of 
vein  wall. 


Fig.  18.     Microscopical  appearances  presented  by  specimen  from  experi- 
ment 43. 

Transverse  section  of  part  of  vein  in  ligated  portion.      X  240. 

strength  to  the  para-vascular  cicatrix,  weaken  the  vessel-walls  at  the 
seat  of  ligation.  I  have  never  observed  a  single  case  in  hospital  or 
private  practice  where  the  catgut  ligature  failed  to  fulfill  in  the  most 
satisfactory  manner  the  purposes  of  a  provisional  haemostatic  agent 
until  the  definitive  cicatrix  had  become  sufficiently  firm  to  resist  the 
intra  arterial  pressure.  In  place  of  severing  the  tunics  of  the  ligated 
vessel  the  catgut  ligature  is  gradually  displaced  1>\  organized  tissue 
which    increases  the  resisting  capacity  of  the  vessel,  providing  an 

13 


194  EXPERIMENTAL  SURGERY. 

additional  safeguard  against  secondary  haemorrhage  if  from  any 
cause  definitive  obliteration  is  retarded.  In  enumerating  the  supe- 
rior advantages  of  the  catgut  ligature,  Nussbaum  says:  "The  most 
careful  microscopical  examinations  have  shown  that  catgut  increases 
to  a  considerable  extent  the  resisting  capacity  of  an  artery  in  forming 
firm  connective-tissue  connections  with  the  vessel." ' 

The  aseptic  animal  ligature  possesses  two  distinct  and  impor- 
tant advantages  over  all  permanent  ligatures:  1.  It  does  not  neces- 
sarily destroy  the  continuity  of  the  vessel.  2.  It  gives  additional 
strength  to  the  extra-vascular  cicatrix.  These  advantages  recommend 
the  animal  ligature  more  particularly  for  the  purpose  of  tying  a 
vessel  in  its  continuity.  I  am  firmly  convinced  that  in  many  of  my 
experiments  the  internal  tunics  of  the  arteries  remained  intact  after 
ligation,  and  yet  cicatrization  progressed  in  a  satisfactory  manner. 
Hence  it  is  no  longer  necessary  to  tie  the  ligature  so  firmly  as  to 
crush  the  tunics  of  the  vessel.  All  that  is  necessary  is  to  tie  with 
sufficient  force  to  approximate  the  inner  surfaces  of  the  intima  with 
a  view  to  insure  effective  provisional  obliteration  of  the  vessel,  when 
cicatrization  will  follow  as  a  necessary  result,  provided  the  vessel 
tunics  are  in  a  healthy  condition.  If  cicatrization  in  a  vessel  takes 
place  from  the  fixed  cells  of  its  tunics  without  the  formation  of  a 
thrombus,  it  will  be  seen  that  in  many  instances  a  vessel  can  be 
ligated  with  safety  in  its  continuity  close  to  a  collateral  branch,  when 
existing  circumstances  dictate  such  a  course. 

One  of  the  rules  invariably  given  by  authors  in  surgery  of 
the  blood-vessels  was  to  make  a  small  opening  in  the  sheath  of  the 
vessel,  only  of  sufficient  size  to  permit  of  passing  the  ligature 
needle  around  it.  It  was  feared  that  a  more  free  opening  in  the 
sheath  and  a  more  extensive  isolation  of  the  vessel  would  lead  to 
necrosis  of  its  tunics  on  account  of  the  cutting  off  of  the  vascular 
supply.  That  this  idea  still  prevails  is  evident  from  one  of  the  most 
recent  text-books  on  surgery.  Lidell  calls  special  attention  to  this 
point  in  the  following  language:  "The  risk  of  sloughing,  however, 
arises  mainly  from  isolating  the  artery  too  much,  or  from  separating 
it  too  extensively  from  its  sheath,  while  dissecting  to  expose  it,  or 
while  preparing  to  pass  a  thread  around  it,  whereby  the  minute 
vessels  which  nourish  its  coats  are  too  extensively  destroyed;  hence 

1  Op.  cit. 


PRACTICAL  SUGGESTIONS.     -  195 

the  dangerousness  of  passing  a  spatula  or  the  handle  of  a  scalpel 
under  the  artery,  and  of  dragging  it  out  of  its  bed  when  tying  it."  ' 

All  of  these  fears  are  unfounded  when  operating  under  antisep- 
tic precautions.  In  all  my  experiments  I  did  all  that  is  here 
cautioned  against:  I  isolated  the  arteries  and  veins  from  their  sheaths 
for  an  inch  or  more,  and  dragged  the  vessel  near  to  the  surface  of 
tlic  wound  in  applying  the  second  ligature,  and  yet  I  never  observed 
any  sloughing  except  in  the  cases  where  the  operation  was  followed 
by  suppuration.  I  am  strongly  in  favor  of  opening  the  sheath 
freely,  so  that  the  operator  can  not  only  feel  but  see  what  he  is  doing, 
and  I  am  convinced  that  by  pursuing  this  course  there  is  less  harm 
done  than  by  operating  in  the  dark. 

My  experiments  on  the  veins  have  taught  me  another  important 
and  practical  lesson,  viz.,  their  tolerance  to  traumatic  insults.  In 
not  one  of  the  cases  was  death  produced  by  the  operation,  although 
in  a  few  of  the  animals  both  the  jugular  and  femoral  veins  were  tied 
at  different  times.  I  never  observed  progressive  phlebitis,  embolism, 
or  pyaemia.  Veins,  like  those  of  the  peritoneum,  may  be  contused, 
torn,  lacerated,  cut,  punctured,  burned,  and  ligated  with  impunity, 
if  infection  is  avoided.  Veins  are  exceedingly  prone  to  infection, 
but  if  infection  can  be  prevented  their  injuries  are  repaired  with 
wonderful  rapidity.  As  regards  the  time  required  for  definitive 
obliteration  to  take  place,  the  results  of  the  experiments  would 
indicate  that  in  the  case  of  arteries  of  the  size  of  the  carotid  or 
femoral  from  four  to  seven  days  are  necessary,  while  in  the  jugular 
vein  the  same  object  is  accomplished  in  three  to  four  days. 

The  double  catgut  ligature  may  be  resorted  to  with  advantage 
in  the  human  subject  in  ligating  large  vessels  in  their  continuity^ 
more  especially  if  the  operation  is  done  near  a  collateral  branch,  as 
it  approximates  the  inner  surfaces  over  a  larger  area  and  thus 
furnishes  a  more  extensive  surface  for  cicatrization.  The  practica- 
bility and  utility  of  the  double  ligature  is,  however,  rendered  most 
apparent  in  the  treatment  of  varicose  veins.  For  many  years  I 
have  successfully  used  the  subcutaneous  double  catgut  ligature  in 
the  treatment  of  varicocele.  In  operating  on  varicose  veins  of  the 
Lower  extremity,  the  intervening  portion  can  readily  be  rendered 
bloodless   by    applying    an    Esmarch's   bandage   before   tying   the 

1  Injuries  of  Bloodvessels.  The  Internat.  Encycl.  of  Surgery,  vol.  iii,  p.  90. 


196  EXPERIMENTAL  SURGERY. 

ligatures.  The  entrance  of  blood  into  the  vessel  between  the  ligatures 
through  small  collateral  branches  can  be  prevented  and  the  process 
of  cicatrization  materially  assisted  by  applying  an  antiseptic  compress 
over  the  seat  of  the  operation  before  removing  the  elastic  bandage. 
A  careful  examination  of  the  literature  on  this  subject,  as  well 
as  the  results  of  my  own  investigations,  warrant  me  in  submitting 
the  following  conclusions: 

1.  All  operations  on  blood-vessels  should  be  done  under  antisep- 
tic precautions. 

2.  The  aseptic  catgut  ligature  is  the  safest  and  most  reliable 
agent  in  securing  provisional  and  definitive  closure  of  blood-vessels. 

3.  A  thrombus  after  ligature  is  an  accidental  formation  which 
never  undergoes  organization  and  takes  no  active  part  in  the 
obliteration  of  the  vessel. 

4.  The  intra-vascular  or  definitive  cicatrix  is  the  exclusive 
product  of  connective  tissue  and  endothelial  proliferation. 

5.  Permanent  obliteration  in  arteries  takes  place  in  from  four 
to  seven  days,  in  veins,  in  from  three  to  four  days. 

6.  In  ligating  vessels  in  aseptic  wounds  the  vessel  sheath  can 
be  opened  freely  without  compromising  the  integrity  of  the  vessel 
tunics,  and  this  procedure  renders  the  operation  safer  and  easier  of 
execution. 

7.  The  double  aseptic  catgut  ligature  should  be  preferred  to 
the  single  ligature  in  ligating  large  arteries  in  their  continuity  near 
a  collateral  branch,  and  should  always  be  employed  in  all  operations 
of  tying  varicose  veins  in  their  continuity  as  the  safest  and  most 

'  effective  measure  in  the  production  of  definitive  obliteration. 


AN  EXPERIMENTAL  AND  CLINICAL  STUDY  OF 
AIR-EMBOLISM.1 


Sudden  and  unexpected  death  during  an  operation  is  a  calamity 
which  never  fails  to  strike  terror  to  the  heart  of  the  boldest  surgeon. 
Although  death  is  a  frequent  and  familiar  visitor  wherever  human 
beings  exist,  nevertheless  its  sudden  and  unforeseen  advent  conveys 
with  it  more  than  the  usual  halo  of  sadness,  and  when  such  a  scene 
transpires  in  the  operating  room  it  leaves  impressions  which  neither 
time  nor  space  can  erase.  Disasters  of  this  kind  come  without 
warning  and  usually  at  a  time  when  least  expected. 

The  surgeon  who  has  the  misfortune  to  meet  with  such  an 
accident  is  not  only  destined  to  burden  his  memory  with  the  unpleas- 
ant remembrances  of  the  incident  for  the  remainder  of  his  days,  but 
in  addition  he  is  often  made  an  unjust  object  of  reproach  by  those 
who  are  unable  to  appreciate  the  nature  of  the  case.  His  conscience 
may  be  relieved  by  a  favorable  verdict  regarding  his  conduct  and 
management  of  the  case  before  the  only  competent  tribunal,  composed 
of  his  colleagues  and  medical  press,  but  that  most  uncertain  of  all 
things,  public  opinion,' will,  in  all  probability,  be  arrayed  against 
him.  In  one  sad  moment  the  object  of  his  ambition,  the  ultimate 
aim  of  his  lifework  has  suffered  irreparable  loss. 

The  surgeon  who  seeks  to  maintain  and  advance  the  interests 
of  his  profession  as  well  as  his  own  reputation,  should  familiarize 
himself  with  all  the  causes  and  conditions  which  may  precipitate 
such  an  unhappy  result,  with  a  view  to  adopt  and  apply  timely 
prophylactic  measures.  Believing  that  it  is  good  practice  to  prepare 
for  war  in  time  of  peace,  I  intend  to  call  attention  to  one  of  the 
most  dreaded  and,  I  may  add,  one  of  the  most  uncontrollable  causes 
of  Midden  death;  I  allude  to  air-embolism. 

Alter  consideration  of  the  subject  from  an  historical,  experi- 
mental, and  clinical   standpoint,  I  shall  endeavor  to  point  out  the 

1  Read  before  the  American  Surgical  Association,  188G. 

1!)7 


198  EXPERIMENTAL   SURGERY. 

conditions,  remote  and  direct,  which  give  rise  to  this  accident.  The 
different  explanations  of  the  immediate  cause  of  death  will  be 
discussed  and,  finally,  I  shall  offer  some  practical  suggestions  relat- 
ing to  prophylactic  and  therapeutic  measures. 

By  air-embolism,  I  understand  the  presence  of  free  atmos- 
pheric air  within  the  vascular  system  during  life  and  in  sufficient 
quantity  to  give  rise  to  symptoms  of  obstruction.  It  is  a  true 
embolism  inasmuch  as  the  location  of  the  volume  of  air  which  consti- 
tutes the  embolus  is  always  some  distance  from  its  point  of  entrance. 
The  presence  of  air  in  a  vessel  offers  the  same  mechanical  obstruc- 
tion to  the  flow  of  blood  as  a  solid  substance,  and  gives  rise  to  the 
same  disturbance  of  circulation  in  the  tissues  supplied  by  the 
vessel. 

An  air-embolus  differs  from  an  ordinary  embolus  in  that,  when 
once  introduced  into  the  circulation,  it  is  capable  of  being  broken 
up  or  divided  by  the  blood  current  and  the  action  of  the  heart,  and 
on  this  account  usually  becomes  the  source  of  multiple  emboli.  It 
also  differs  pathologically  from  a  solid  embolus,  since  it  is  more 
likely  to  be  removed  by  absorption  and  is  less  liable  to  be  followed 
by  thrombosis.  Air-embolism  is  always  due  to  the  introduction  of 
atmospheric  air  into  a  wounded  or  injured  vein,  and,  in  contra- 
distinction to  the  ordinary  form  of  embolism,  it  is  primarily  almost 
always  formed  in  the  right  side  of  the  heart  and  in  the  venous 
system.  In  order  to  study  the  immediate  effects  of  the  presence  of 
a  considerable  amount  of  air  on  the  heart  and  the  vessels,  it  becomes 
necessary  to  allude  to  the  experiments  where  embolism  was  arti- 
ficially produced  by  the  introduction  of  solid  substances  into  the 
circulation. 

I.    The  Immediate  Cause  of  Death  in  Rapidly  Fatal 

Embolism. 

The  most  interesting  experiments  on  embolism  were  made  by 
Virchow,  in  1847,  and  by  Panum,  in  1854-1855,  and  although  the 
conclusions  of  these  experimenters  are  somewhat  at  variance,  our 
present  knowledge  on  this  subject  is  based  upon  the  conjoined  labors 
of  these  distinguished  writers. 

Virchow  was  convinced  that  his  experiments  were  conclusive  in 
showing   that   complete  embolism  of  the  pulmonary  artery  would 


IMMEDIATE    CAUSE    OF  DEATH  IN  EMBOLISM.  199 

invariably  prove  fatal  in  a  short  time,  while  partial  obliteration  of 
this  vessel  produces  either  no  symptoms  at  all,  or  only  temporary 
dyspnoea,  restlessness,  and  a  sense  of  oppression.  He  gives  the  fol- 
lowing explanation  to  account  for  the  immediate  cause  of  death  in 
cases  of  complete  obstruction  of  the  pulmonary  artery  by  a  large 
embolus:1  "The  first  effect  of  the  pulmonary  ischsemia  is  the 
interruption  of  the  supply  of  oxygenated  blood  to  the  coronary 
arteries  of  the  heart  and  the  arteries  of  the  body,  as  well  as  the 
stasis  of  the  venous  blood  in  the  right  side  of  the  heart,  the 
coronary  veins,  and  the  veins  throughout  the  body.  These  conditions 
result  in  the  arrest  of  the  heart's  action  in  the  diastole,  the  tetanic 
contractions  of  the  voluntary  muscles,  the  retardation  of  respira- 
tion, the  dilatation  of  the  pupils,  the  protrusion  of  the  eyeballs,  etc., 
and  very  soon  complete  death." 

Panum,  by  a  series  of  very  ingenious  experiments,  disproved 
the  assertions  of  Yirchow,  that  a  lack  of  arterial  blood  in  the  coro- 
nary arteries  produces  instantaneous  arrest  of  the  heart's  action. 2 
In  a  rabbit,  where  the  ventricular  contractions  had  ceased  for  fully 
fifteen  minutes  and  where  only  the  right  auricle  continued  to  pulsate, 
he  injected  a  warm  black  mass,  composed  of  tallow,  wax,  and  soot, 
into  the  aorta,  for  the  purpose  of  studying  more  accurately  the 
anatomical  relations  of  the  coronary  arteries.  The  injection  pene- 
trated the  smallest  vessels.  The  right  auricle  continued  its 
rhythmical  movements  for  three  hours  and  a  half  after  the  injection 
was  made,  the  heart  and  lungs  having  been  removed  from  the  body. 

In  a  second  experiment  he  divided  both  pneumogastric  nerves 
in  a  dog,  and  then  opened  the  chest  and  the  pericardium  and  passed 
a  double  ligature  underneath  the  innominate  artery ;  after  tying  the 
upper  ligature  and  drawing  the  lower  tight,  the  artery  was  opened 
between  them,  and  a  silver  tube  introduced  and  secured  in  the  vessel 
with  the  proximal  ligature.  The  silver  tube  was  connected  with  a 
glass  tube  by  a  piece  of  rubber  tubing.  To  the  distal  end  of  the 
glass  tube  another  piece  of  rubber  was  attached  and  all  the  tubes 
filled  with  oil,  which  was  prevented  from  escaping  by  a  clamp.  The 
aorta  was  compressed  with  a  spring  forceps  above  the  origin  of  the 
innominate  artery  and  the  same  black  mass  was  injected  through 
the  tubes  into  the  aorta.     Tim  oil  ami  black  mass  entered  the  vessel, 

1  Gesarniiicltc  Ahhaiidlun^cii,  p.  2'.t7. 

2  Exper.  Beitriige  zur  Lehrev.d.  Embolic.   Virohow's  Archiv,  xxv.  p. 808. 


200  EXPERIMENTAL  SURGERY. 

and  after  closing  the  aortic  valves  filled  the  coronary  arteries,  which 
were  found  completely  blocked  with  the  foreign  substance. 

The  movements  of  the  heart  were  carefully  observed  before, 
during,  and  after  the  injection  was  made.  Before  the  injection,  the 
contractions  were  regular,  eighty  to  ninety  per  minute;  during  the 
injection,  on  account  of  the  higher  temperature  of  the  injection 
(45°  C),  the  contractions  became  more  rapid,  and  in  the  left  side  of 
the  heart,  which  was  distended  with  blood,  they  were  less  forcible,  an 
occurrence  which  could  be  readily  accounted  for  by  the  mechanical 
obstruction  to  the  outflow  from  the  left  ventricle.  All  the  chambers 
of  the  heart  continued  to  contract  for  five  minutes  after  the  injection 
was  complete.  Six  minutes  after  the  injection  was  made,  the  con- 
tractions of  the  left  auricle  ceased.  The  movements  of  the  ventricles 
were  feeble,  but  could  be  plainly  seen.  The  rhythm  of  the  ven- 
tricular contractions  grew  slower  than  the  contractions  of  the  right 
auricle,  and  at  the  same  time  were  less  regular. 

After  twenty-five  minutes  the  right  auricle  pulsated  forty-eight, 
the  ventricles  twenty- four  times  per  minute.  Five  minutes  later 
the  pulsations  of  the  auricle  and  ventricles  were  the  same  in 
frequency.  Forty  minutes  after  the  injection  the  ventricles  con- 
tracted twenty-four  times  per  minute  to  eight  auricular  pulsations. 
Fifty  minutes  after  the  injection  the  ventricles  made  twenty-three 
rhythmical  movements  to  three  of  the  auricles.  After  one  hour  the 
movements  of  the  heart  again  became  regular,  inasmuch  as  the 
auricles  and  ventricles  pulsated  thirteen  times  per  minute,  and  in 
such  a  manner  that  the  movements  of  the  ventricles  followed 
immediately  after  the  contraction  of  the  auricles  and  were  followed 
by  a  long  diastolic  pause. 

Seventy-five  minutes  after  the  injection,  the  movements  of  the 
left  ventricle  ceased,  while  the  right  half  of  the  heart  contracted 
regularly  eight  times  per  minute.  Two  minutes  later  the  ventricle 
contracted  only  twice  to  eight  movements  of  the  auricle.  Ninety  min- 
utes after  the  injection,  the  right  ventricle  ceased  to  beat,  while  the 
right  auricle  continued  to  contract  for  six  hours  and  ten  minutes  after 
the  injection,  making  toward  the  last  only  one  movement  per  minute. 
After  all  pulsations  had  ceased  for  a  while,  they  were  renewed  by 
blowing  upon  the  heart.  These  contractions  continued  for  seven 
hours  and  a  half  after  the  injection,  and  even  after  they  had  ceased 
for  a  second  time  they  were  again  excited  by  mechanical  irritation. 


IMMEDIATE   CAUSE   OF  DEATH   IN  EMBOLISM.  201 

During  this  observation  the  heart  was  kept  at  a  temperature  of 
12.5°  to  13  C.  under  a  glass  bell  in  which  the  air  was  saturated 
with  moisture.  An  examination  of  the  heart  showed  that  the 
coronary  arteries  were  completely  distended  with  the  black  mass, 
and  that  the  capillary  vessels  and  coronary  veins  were  blocked  with 
oil.  A  few  drops  of  oil,  but  nothing  of  the  black  mass  were  found 
in  the  right  auricle.  The  aorta  near  the  heart  was  filled  with  the 
injection  material,  and  the  aortic  valves  were  so  completely  closed 
that  nothing  had  penetrated  into  the  ventricle.  In  two  other 
instances  the  coronary  arteries  were  made  impermeable  in  a  similar 
manner,  and  the  contractions  of  the  heart  were  temporarily  arrested 
by  electric  irritation  of  the  pneumogastric  nerves.  This  experiment 
was  repeated  in  both  animals  more  than  twenty  times,  and  always 
with  the  same  uniform  result.  If  the  electric  stimulation  was  con- 
tinued after  the  heart  had  ceased  to  contract,  the  movements  were 
again  excited,  but  this  always  required  a  continuation  of  the  current 
for  at  least  a  minute.  If  the  electrodes  were  removed  after  the 
heart  ceased  to  act,  it  required  twenty  seconds  before  the  contrac- 
tions were  re-established,  the  movements  being  always  more  rapid 
than  before  the  irritation  was  applied. 

From  these  experiments  we  are  forced  to  conclude  that  embolism 
of  the  coronary  arteries  is  insufficient  to  produce  instantaneous 
arrest  of  the  heart's  action.  Virchow  quotes  Erichsen  as  having 
observed  prompt  cessation  of  the  movements  of  the  heart  after 
ligation  of  the  coronary  arteries,  but  Panum  doubts  the  possibility 
of  performing  this  operation  upon  the  heart  of  a  living  animal. 

The  same  observer  studied  embolism  of  the  pulmonary  artery 
by  Injecting  an  emulsion  of  gum-arabic,  in  which  were  suspended 
small  pellets  of  black  wax,  into  the  jugular  vein  of  a  medium-sized 
dog.  Eight  cubic  centimeters  of  the  emulsion  were  injected.  All 
signs  of  life  and  all  reflex  movements  ceased  three  minutes  after  the 
injection.  After  death  the  large  vessels  were  tied,  in  order  to  ascer- 
tain the  exact  quantity  of  blood  contained  in  each  side  of  the  heart. 
The  right  side  contained  112.35  grammes  of  dark-colored  blood,  the 
left  contained  only  0.45  grammes.  In  another  experiment  he 
injected  coarsely  powdered  charcoal  in  suspension,  into  tho  jugular 
vein  of  B  dog.  The  time  which  elapsed  between  the  injection  and 
cessation  of  life  was  longer  than  in  the  preceding  case,  consequently 
the  left   heart  contained  a  larger  amount  of  blood,   although  the 


202  EXPERIMENTAL   SURGERY. 

quantity  was  small  when  compared  with  that  in  the  right  side  of 
the  heart. 

In  all  cases  of  death  resulting  from  embolism  of  the  pulmonary 
artery,  the  amount  of  blood  found  in  the  left  side  of  the  heart  is 
proportionate  to  the  completeness  of  the  obstruction  in  the  pulmon- 
ary artery.  The  left  side  of  the  heart  is  never  found  completely 
empty,  as  the  labored  respiratory  movements  will  force  the  blood, 
which  is  present  in  the  pulmonary  vein  and  its  branches,  into  the 
left  side  of  the  heart.  If  instead  of  using  small  emboli  large  plugs 
are  injected,  as  was  done  by  Virchow,  the  blood  contained  on  the 
distal  side  of  the  obstruction  will  pass  through  the  pulmonary  circu- 
lation and  reach  the  left  side  of  the  heart,  consequently  in  such 
cases  more  blood  will  be  found  in  the  left  ventricle. 

Panum  asserts  also  that  cessation  of  the  heart's  action  does  not 
invariably  take  place  so  early  that  it  can  be  considered  as  the 
primary  and  direct  cause  of  death.  As  a  rule,  he  found  the  heart 
pulsating  after  the  death  struggle  had  been  initiated  from  arrest  of 
innervation  from  the  cerebro-  spinal  center.  In  some  instances  the 
heart  continued  to  pulsate  after  all  signs  of  animal  life  emanating 
from  the  brain  and  spinal  cord  had  ceased.  Shortly  after  respira- 
tion was  arrested  the  heart  did  cease  to  pulsate,  and*  as  Virchow  has 
stated,  in  the  diastole. 

According  to  Panum,  the  cessation  or  continuation  of  the  heart's 
action  exerts  no  influence  for  good  or  evil  in  cases  of  extensive 
embolism.  He  claims  that  if  the  cessation  of  the  heart's  action  takes 
place  as  one  of  the  first  effects  after  embolism  of  the  pulmonary 
artery,  as  was  noted  in  Virchow' s  first  case,  it  must  be  regarded, 
under  certain  circumstances,  as  being  the  result  of  irritation  of  the 
pneumogastric  nerves,  and  so  much  the  more  as  the  heart,  in  the 
case  referred  to,  again  began  to  pulsate  after  the  thorax  was  opened. 
As  a  rule,  the  heart's  action  is  arrested  by  distention  of  the  right 
ventricle. 

Other  observations  tend  to  show  that  the  distention  of  the  right 
ventricle  is  the  cause.  The  excess  of  carbonic  acid  gas  and  the 
diminished  supply  of  oxygen  must  also  be  taken  into  account.  Other 
experiments  have  demonstrated  that  carbonic  acid,  in  concentrated 
form,  injected  into  tha  heart  after  its  removal  from  the  chest,  readily 
leads  to  diastolic  paralysis,  and  that  the  organ  commences  to  beat 
again  when  exposed  to  air.      The  arrest  of  the  heart's  action  is  due 


IMMEDIATE   CAUSE   OF  DEATH   IX  EMBOLISM.  203 

to  mechanical  dilatation  and  the  presence  of  an  excess  of  carbonic 
acid. 

The  first  and  most  constant  symptom  resulting  from  sudden 
and '  extensive  embolism  is  a  high  degree  of  anrernia  in  all  visible 
parts  of  the  body.  On  post-mortem  examination  the  white  substance 
of  the  brain  is  completely  bloodless,  especially  if  small  and  numerous 
emboli  have  been  injected.  This  general  anaemia  is  followed  by 
tetanic  stretching  of  all  extremities,  involuntary  discharges,  and  deep, 
convulsive,  inspiratory  movements.  Ligature  of  both  carotid  arteries 
does  not  produce  such  an  intense  ischsemia  of  the  brain.  If  the 
vertebral  arteries  are  ligated  at  the  same  time,  the  tightening  of  the 
ligature  of  the  second  vertebral  artery  produces  syncope  and  convul- 
sions, but  the  symptoms  are  less  intense  than  after  sudden,  fatal 
embolism  of  the  pulmonary  artery. 

Panum  also  induced  cerebral  anaemia  by  injecting  black  pellets 
of  wax,  suspended  in  an  emulsion,  into  the  crural  artery  of  a  dog, 
throwing  the  injection  in  a  central  direction  through  a  catheter  which 
had  been  passed  into  the  artery  near  the  heart,  producing  thus 
multiple  embolism  in  all  of  the  smaller  arteries.  The  animal  lost 
only  a  few  drops  of  blood,  and  no  air  entered.  The  animal  was 
taken  immediately  with  tetanic  convulsions  and  involuntary  dis- 
charges, and  all  organs  accessible  to  the  eye  presented  an  extremely 
anaemic  appearance.  All  reflex  symptoms  were  arrested  after  one  to 
two  minutes.  Two  other  experiments  were  followed  by  the  same 
results.  In  all  cases  the  small  wax  pellets  were  found  in  large  num- 
bers in  the  small  vess.els  of  the  brain,  as  well  as  in  all  other  parts  of 
the  body. 

In  four  other  dogs  cerebral  embolism  was  avoided  by  introducing 
the  catheter  only  as  high  as  the  ribs,  and  by  injecting  slowly.  During 
the  injection  a  peculiar  tremor  was  observed,  which  affected  the 
muscles  of  the  lower  extremities;  this,  however,  soon  ceased,  and 
gave  way  to  complete  paralysis  of  both  motion  and  sensation,  as 
well  as  complete  arrest  of  all  reflex  movements.  The  first  animal 
survived  the  experiment  twenty-two  hours,  the  second  nine  and  a 
half  hours,  the  third  six  hours,  and  the  fourth  five  hours.  The 
small  vessels  of  the  spinal  cord  were  found  obstructed  by  the  small 
wax  pellets,  the  vessels  between  the  emboli  and  the  heart  were  much 
dilated,  and  showed  many  small  e.\1  ravasai  ions.  The  spinal  cord  was 
the  seat  of  red  softening,  which  was  more  conspicuous  the   longer 


204  EXPERIMENTAL  SURGERY. 

the  life  of  the  animal  was  prolonged.  The  spinal  cord  above  the 
middle  of  the  dorsal  region  and  the  brain  were  normal  in  appear- 
ance, although  scattering  pellets  were  found  here  also. 

It  will  be  seen  that  Panum,  in  contradistinction  to  Virchow, 
attributes  the  immediate  cause  of  death  in  cases  of  rapidly  fatal 
embolism  to  acute  cerebral  anaemia. 

From  a  study  of  the  literature  on  air- embolism,  it  is  evident 
that  the  immediate  cause  of  death  has  been  assigned  by  different 
pathologists  to  one  of  the  following  conditions : 

1.  Mechanical  dilatation  of  the  heart  and  paralysis  of  the  organ 
in  the  diastole. 

2.  Acute  cerebral  ischsemia. 

H.  Asphyxia,  resulting  from  mechanical  obstruction  to  the  pas- 
sage of  the  blood  through  the  pulmonary  circulation. 

As  we  shall  see  further  on,  death  from  air-embolism  is  not 
always  produced  in  the  same  manner;  the  mode  of  dying  varies  and 
is  modified: 

1.  By  the  amount  of  air  admitted. 

2.  By  the  time  which  has  elapsed  between  the  ingress  of  air 
and  the  fatal  issue. 

3.  By  the  location  and  distribution  of  the  emboli. 

II.    History  of  Air-Embolism. 

Surgeons  and  pathologists  have  for  a  long  time  been  aware  of 
the  deleterious  effects  of  free  atmospheric  air  in  the  vascular  system. 
The  danger  attending  the  forcible  insufflation  of  air  into  the  veins 
of  animals  was  well  known  to  many  of  the  earlier  physiologists. 
Among  the  first  to  study  the  effects  of  the  introduction  of  air  into 
veins  may  be  mentioned  Redi,  Wepfer,  Camerarius,  De  Heyde,  Harder, 
Bohnius,  Boerhaave,  Lancisi,  Morgagni,  Valsalva,  Bichat,  andNysten. 

As  early  as  1667  Redi  killed  animals  by  intravenous  injections 
of  air.  He  observed  during  his  experiments  that  the  pulse  became 
intermittent,  an  occurrence  which  he  attributed  to  the  passage  of  a 
large  air  bubble  through  the  heart.  His  followers  who  repeated  the 
experiments,  soon  discovered  that  after  forcible  insufflation  of  air 
into  veins  the  air  became  diffused,  inasmuch  as  at  the  post-mortem 
examinations  they  found  it  present  in  the  right  auricle,  the  coronary 
vessels  and,  in  the  shape  of  air  bubbles,  in  the  smaller  vessels. 


HISTORY   OF  AIR-EMBOLISM.  205 

Merg  made  the  observation  that  on  opening  the  abdomen  of  a 
dog  and  puncturing  the  vena  cava  above  the  origin  of  the  emulgents, 
as  the  vein  became  emptied  of  blood  it  tilled  with  air  which  ascended 
with  the  blood  current  and  entered  the  right  side  of  the  heart. 
Haller  witnessed  the  same  phenomenon  in  cold-blooded  animals  after 
wounding  some  of  the  large  venous  trunks.  He  has  shown  that  it 
was  from  this  source  that  the  air  was  derived  which  Redi,  Caldesi, 
and  Morgagni  had  seen,  circulating  in  the  vessels  of  the  same 
animals.  He  claimed  that  air  is  never  seen  in  vessels  when  the 
necessary  precautions  are  exercised  to  prevent  its  introduction  through 
a  wounded  vein.  Nysten  found,  by  injecting  air  slowly  into  a  vein, 
so  as  not  to  produce  the  death  of  the  animal,  that  the  coloring  of 
the  arterial  blood  was  rendered  imperfect.  He  satisfied  himself  that 
this  change  was  not  owing  to  the  embarassment  of  respiration. 
Insufflation  of  oxygen  had  no  effect  in  preventing  or  correcting  this 
change  of  color  in  the  arterial  blood. 

The  literature  on  insufflation  of  air  into  veins  is  quite  prolific 
and  this  subject  cannot  be  justly  passed  over  without  an  allusion  to 
the  following  names  which  are  intimately  associated  with  the  experi- 
mental part  of  the  history  of  air-embolism: 
Blochmann.     Aer  in  venis  causa  mortis.     Dresden,  1843. 
Bouillaud.     De  l'introduction  de  l'air  dans  les  veines.     Paris,  1838. 
Gain.     De  aeris  ingressione  in  venas.     Berlin,  1865. 
Maguin.       Etude    experimental    sur    l'introduction  forcee    et    sur  l'entree 

spontanee  de  l'air  dans  les  veines.    Nancy,  1879. 
Meric.  Recherches  sur  l'introduction  de  l'air  et  des  gaz  qui  le  constituent  dans 

le  systeme  veineux.     Paris,  1866. 
Valkenhoff.     De  aeris  in  venas  ingressu  ejusque  effectu  lethali.     1840. 
Laborde.      Effets  de  l'introduction  de    l'air    dans    la  circulation    arterielle. 

Compt.  Rend.  Soc.  de  Biolog.     Paris,  1873. 

It  was  not  long  after  the  deleterious  effects  of  free  atmospheric 
air  in  the  veins  of  animals  had  been  studied  experimentally  before 
the  same  symptoms  were  observed  in  man  by  the  accidental  admis- 
sion of  air  into  wounded  veins  during  operations,  and  in  some  of 
the  first  cases  the  presence  of  air  in  the  veins  and  right  side  of 
the  heart  was  demonstrated  by  post-mortem  examination.  Although 
a  number  of  honest  and  reliable  surgeons,  prominent  among  them 
Velpeau  and  Fergusson,1  have  denied  that  a  sufficient  amount  of  air 

1  Lettre  sur  l'introduction  de  l'air  dans  les  veines  de  L'homme.  Gazette 
M6dicale.    Paris,  1838,  pp.  113-121. 


206  EXPERIMENTAL  SURGERY. 

can  be  admitted  through  a  wounded  vein  to  produce  sudden  death, 
this  assertion  is  no  longer  tenable  in  the  face  of  such  a  large  number 
of  well-authenticated  cases  as  have  been  recorded  in  surgical  litera- 
ture by  equally  conscientious  and  competent  observers.  Since  the 
publication  of  the  first  well -authenticated  case  observed  by  Beauchene 
and  described  by  Magendie,  the  following  authorities,  placed  in 
alphabetical  order,  have  reported  similar  cases: 
Amussat.    Introduction  de  l'air  dans  les  veines.    Bulletin  Acad,  de  Med.,  Paris, 

i.  pp.  894,  899,  1836;  ii.  pp.  363,  461,  1837-38. 
Assmus.     Zur  Casuistik  des  Lufteindringens  in  grossere  Venenstamme.    Med. 

Zeitung,  xi.  p.  104.     Berlin,  1842. 
Barlow.     An  Attempt  to  remove  a  Tumor  on  the  Neck;  Entrance  of  Air  in 

Vein;  Sudden  Death.     Med.-Chir.  Trans.,  xvi.  pp.  28-35,  1830. 
Chassaniol.    Observation  de  l'entree  de  l'air  dans  les  veines  pendant  l'amputa- 

tion  du  bras,  dans  son  articulation  scapulo-humerale.     L'Union  Medicale, 

viii.  p.  428.     Paris,  1869. 
Clemot.     Lane.  Franc,  torn.  i.  p.  357,  1830. 
Coolidge.    Case  of  Sudden  Death  from  Entrance  of  air  into  the  Jugular  Vein. 

New  York  Med.  Gazette,  i.  p.  305,  1841-2.      Also  New  York  Med.  Journal, 

vol.  ix.  pp.  199-201,  1847. 
Cooper,  B.     Case  of  Alarming  Syncope  from  the  Admission  of    Air  into   a 

Vein,  During  Amputation  of  the  Shoulder-Joint.     The  Lancet,  i.  pp.  448- 

451,  1843. 
Cormack.     Case  of  Death  from  the  Entrance  of  Air  by  a  Rigid  Vein  in  the 

Neck,  Opened  Accidentally  by  a  Seton-Needle.     Lond.,Med.  Jour.,  1850. 
Delaporte.   Extirpation  l'une  tumeur  situee  au  cou;  introduction  de  l'air  dans 

le  systeme  vasculair.     Bulletin  Acad,  de  Med.,  i.  p.  132.     Paris,  1836. 
Delpech.     Mem.  des  hopitaux  du  midi,  No.  16,  p.  231,  1830. 
Fischer,  H.     Ueber  die  Gefahren  des  Lufteintritts  in  die  Venen  wahrend  einer 

Operation.     Volkmann's  Sammlung  klin.  Vortrage,  Chirurgie.  No.  34. 
Gunn.     Syncope    from    Entrance  of    Air   into    the   Facial  Vein.     New  York 

Medical  Journal,  p.  356, 1852. 
Heckford.     Four  Cases  of  Entry  of  Air  into  the  Circulation.     Medical  Times 

and  Gazette,  i.  p.  137.     London,  1867. 
Koestlin.     Ein   Fall  von  Luft  im  Herzen.     Med.  Correspondenzblatt  d.  wurtt. 

arztl.  Ver.,  xxviii.  pp.  316-321.     Stuttgart,  1857. 
De  Lavacherie.     De  l'opportunite  de  l'extraction  des  tumeurs  du  cou  non  sus- 

ceptibles  de  resolution;  reflexions  sur  l'introduction  de  l'air  dans  le  coeur 

par  des  veines  ouvertes  accidentellement.     Mem.  Acad.  Roy.  de   M6d.  de 

Beige,  ii.  pp.  305-376.     Bruxelles,  1849. 
McPharlin.    Death  from  Entrance  of  Air  into  the  Veins  in  a  Case  of  Compound 

Fracture.     Hosp.  Gazette,  iii.  p.  20.     New  York,  1878. 
Massart.      Etude  nouvelle  sur  l'entree  de  l'air  dans  les  veines,  dans  les  cas  de 

plaie  ou  d'operation  chirurgicale.    Annales  Societe  de  Medecine  d'Anvers, 

xv.  pp.  5,  57,  113,  1854. 


INTRAVENOUS  PRODUCTION   OF  AIR.  207 

Mercier.    Journal  des  connaiss,  p.  108,  September,  1836. 

Meyer,  F.      Case  of  Injury  of  the  Vena  Jugularis  Interna;  Entrance  of  Air; 

Sudden  Collapse;  Recovery.    Med.  Arch.,  iii.  pp.  408-410.    St.  Louis,  1869. 
Miner.     Tumor  in  the  Neck;  Admission  of  Air  into  the  Vein;  Death.    Buffalo 

Med.  and  Surg.  Journal,  pp.  336  338,  1864. 
Mirault.     These.     Paris,  1832.^    . 

Mott.     Entrance  of  Air  into  the  Facial  Vein.     Medico-Chir.  Trans.,  1830. 
Piachaud.     Mort  par  introduction  de  Pair  dans  une  veine  pendant  l'ablation 

d'nne  tumeur  du  sein  avec  ganglions   dans   l'aisselle.        Echo    Medical, 

p.  768.     Neuchatel,  1857. 
Porter.     On  the  Entrance  of  Air  into  the  Veins  as  a  Cause  of  Death.    Journal 

American  Med.  Assoc,  iii.  No.  20.  , 

Rauch.      Lufteintritt  in  einen  verletzten  grosseren  Halsvenenast  und  seine 

Folgen.     Oest.  Med.  Wochenschr..  pp.  199-201.     Wien,  1845. 
Roux.     Journal  Hebdomadaire,  ii.  p.  64,  1833. 
Schmid.     Das  Eindringen  von  Luft  in  eine  Vene  wahrend  einer  Operation  am 

Halse.     Corresp.  blatt  d.  w&rtt.  arzt.  Ver.,  xxi.  p.  53.     Stuttgart,  1851. 
Schweickhart.      Eindringen  von  Luft  in  die  Venen;  Tod  durch  Gehirnschlag. 

Mitth.  des  badischen  arzt.  Ver.,  vi.  pp.  69-71.     Karlsruhe,  1852. 
Smith,   R.  W.     Abscess  behind    the    Pharynx;    Entrance  of   Air  into  Veins. 

Dublin  Quarterly  Journal  Med.  Sciences,  xxv.  p.  497,  1844. 
Tadlock.    Entrance  of  Air  into  Divided  Internal  Jugular  Vein;  Ligation;  Re- 
covery.    American  Journal  of  Medical  Sciences,  p.  280,  1875. 
Ulrich.     Tod  durch   Eintritt  von  Luft  in  die  Venen.      Med.  Zeitschrift  des 

Vereins  fur  Heilkunde,  p.  132,  November,  1834. 
Warren,  J.  C.     Two  Cases  of  Accidents  from  Admission  of  Air  into  the  Veins 

during  Surgical  Operations.     Am.  Jour.  Med.  Sci.,  pp.  545-548,  1832. 
Warren,  J.  M.    Tumor  Connected  with  the  Sartorius  Muscle;  Secondary  Cancer 

of  Breast;  Operation;  Entrance  of  Air  into  the  Vein;  Recovery.   Surgical 

Observations,  p.  529.     Boston,  1867. 
Wattmann.     Prager  Vierteljahrsschrift,  ii.  p.  191,  1844. 

This  list  is,  of  course,  not  complete,  nor  does  it  represent  all 
the  cases  of  accidental  introduction  of  air  during  operations;  but 
the  names  which  are  quoted  ought  to  be  accepted  as  sufficient 
guarantee  by  the  most  skeptical  that  the  fear  of  this  accident  is  not 
a  myth,  but  a  reality  substantiated  by  many  a  sad  experience. 

III.    Intravenous  Production  of  Air. 

Spontaneous  production  of  air  within  the  blood-vessels  of 
recently  deceased  persons  has  been  repeatedly  observed,  and  to  it 
has  been  assigned  one  of  the  causes  of  sudden  death.  That  the  air 
thus  produced  is  a  direct  product  from  the  blood  appears  to  be 
negatived  by  the  fact  that  its  occurrence  has  usually  been  traced  in 


208  EXPERIMENTAL   SURGERY. 

connection  with  sudden  and  exhaustive  haemorrhages.  It  is,  in  fact, 
in  persons  who  have  died  from  haemorrhage,  that  air  has  been  found 
in  greatest  abundance  in  the  veins.  Lieutand1  reports  the  case  of 
a  girl  who  died  suddenly  in  a  state  of  syncope,  after  having  been 
repeatedly  bled,  and  in  whom  the  cerebral  veins  and  choroid  plexus 
were  found  impacted  with  air.  M.  Rerolle 2  has  published  several 
cases  of  the  kind,  where  profuse  haemorrhage  had  existed;  in  one 
of  fatal  epistaxis,  the  heart,  arteries  and  veins  contained  large 
quantities  of  air.  Dr.  Graves  has  noticed  emphysema  of  the  abdominal 
parietes  in  a  sufferer  from  repeated  attacks  of  epistaxis.  M.  Rerolle 
conjectures  that,  in  such  cases,  air  is  absorbed  by  the  radicles  of  the 
pulmonary  veins — the  air  would  have  no  claim  to  be  considered 
adventitious.3 

It  is,  however,  more  logical  to  assume  that,  as  in  almost  all 
cases  the  supposed  intravenous  origin  of  air  took  place  after  severe 
loss  of  blood  together  with  loss  of  continuity  of  the  vascular  system, 
owing  to  the  sudden  loss  of  intravascular  pressure,  the  air  may  have 
been  aspirated  through  the  openings  of  some  of  the  bleeding  vessels. 
The  quantity  of  air  found  in  these  cases  has  been  so  small  that  it 
has  been  impossible  to  make  a  chemical  examination  to  determine 
its  identity  with  atmospheric  air.  In  cases  where  air  was  found  in 
blood  without  loss  of  continuity  of  the  vessels,  it  is  not  impossible 
that  the  supposed  air  was  not  atmospheric  air,  but  a  gaseous  product 
liberated  from  the  blood  or  generated  in  the  tissues,  producing  a 
gas-embolism  which  interfered  with  the  function  of  circulation  in  a 
similar  manner  as  when  the  obstruction  was  caused  by  atmospheric 
air. 

IV.  Effect  of  the  Heart  and  Respiration  on  the  Venous 

Circulation. 

As  the  state  of  the  intravenous  blood  pressure  constitutes  the 
most  important  element  both  in  the  prevention  and  causation  of 
aspiration  of  air  into  veins,  this  subject  must  be  briefly  alluded  to  in 
order  to  determine  the  conditions  which  act  as  exciting  causes.  For 
the  most  reliable  and  comprehensive  information  on  this  subject  we 

1  Hist.  Anat.,  Med.  Obs.  55. 

2  Thfcse  de  Paris,  No.  129,  1832. 

3  Todd's  Cyclopaedia  of  Anat.  and  Physiol.,  vol.  iv.  part  i,  p.  145. 


INTRAVENOUS  BLOOD   PRESSURE.  209 

are  indebted  to  Dr.  Heinrich  Jacobson.1  The  observations  were 
made  on  sheep.  To  determine  the  effect  of  the  heart's  action  upon 
the  venous  circulation  he  measured  the  blood  pressure  in  veins  with 
the  manometer.  These  measurements  were  made  on  veins  in  close 
proximity  to  the  heart,  as  the  lower  portion  of  the  jugular  and  sub- 
clavian, as  all  attempts  to  approach  nearer  the  heart  seriously 
impaired  the  normal  physiological  conditions  of  the  respiratory  and 
circulatory  organs.     This  measurement  gave  the  following  results : 

In  the  left  vena  anonyma — 0.1  mm.  Hg. 

"     "    right    "      jugularis +0.2      "       " 

"     "    right   "      subclavia — 0.1      "       " 

"     "    left      "      jugularis —0.1      "       " 

"     "    left      "      subclavia —0.6      "       " 

The  following  are  his  observations  on  some  of  the  more  distal 
veins  in  the  same  animal: 

In  the  external  facial  vein -(-3.0  mm.  Hg. 

"     "    internal        "  "    +5.2     "       " 

"     "    brachial  vein +4.1     "       " 

"  a  branch  of  the  brachial +9.0      "       " 

"  the  crural  vein +11.4    "       " 

The  experiments  of  Ludwig  and  Mogk,  although  made  in  a 
similar  manner,  led  to  more  variable  and  inconstant  results ;  at  one 
time  they  found  the  blood- pressure  in  the  crural  vein  6.8  mm.  Hg., 
while  on  another  occasion  under  similar  circumstances  it  measured 
in  the  same  vein  only  1.9  mm.  Hg.  Donders  explains  this  want  of 
uniformity  by  the  respiratory  movements  of  the  chest,  believing  that 
the  aspiratory  movements  of  the  chest  affect  the  venous  circulation 
more  than  the  vis  a  tergo  from  the  capillary  system. 

Poisenille  claimed  that  in  his  experiments  the  manometer  was 
affected  by  the  respiratory  movements  of  the  chest  only  when  it  was 
inserted  into  veins  in  close  proximity  to  the  heart,  as  in  the  lower 
portion  of  the  jugular  and  the  external  iliac  veins,  while  in  more 
distant  veins  the  column  of  mercury  was  not  affected  by  the  move- 
ments of  the  chest.     Volkmann  obtained  the  following  measurenx  i  il  s : 

In  the  facial  vein  of  a  goat 41  mm.  Hg. 

"     "     jugular  vein  of  a  goal 18  "         " 

"     "    metatarsal  vein  of  a  calf 27  "         " 

"     "     jugular  vein  of  a  calf 21.5  "         " 

"  a  subcutaneous  vein  of  the  neck  of  a  horse  44  "         " 

"  the  jugular  vein  of  a  horse 21 .5  "         " 

1  Ueber  Blutbewegung  in  den  Venen.      Virchow's  Archiv,  xxxvi.  p.  80. 
14 


210  EXPERIMENTAL   SURGERY. 

Magendie  found  the  blood-pressure  in  the  external  jugular  vein 
of  a  dog  18  mm.  Hg.,  and  in  the  crural  vein  50  mm.  Hg.  Although 
the  measurements  of  the  intravenous  blood-pressure  taken  by 
different  observers  are  at  great  variance,  and  although  their  figures 
are  indicative  of  the  opinions  held  by  the  different  experimenters  as 
to  the  effect  of  respiration  upon  the  return  of  venous  blood,  yet 
they  all  agree  in  locating  the  minimum  degree  of  intravenous  pres- 
sure in  the  veins  nearest  the  heart. 

The  effect  of  respiration  on  the  venous  circulation  was  thor- 
oughly investigated  by  Magendie.  He  introduced  an  elastic  tube 
into  the  internal  jugular  vein,  and  observed  that  blood  would  escape 
only  during  expiration.  The  same  experiment  was  made  on  the 
crural  vein  by  directing  the  tube  toward  the  heart,  and  was  followed 
by  the  same  result.  The  suction  force  exerted  during  inspiration 
was  sufficient  to  counter-balance  the  auricular  contractions.  In 
making  these  experiments  air  was  frequently  drawn  into  the  heart 
during  forcible  inspiration.  Barry  introduced  through  the  jugular 
vein  of  a  horse  a  bent  tube  of  glass,  one  extremity  being  passed  into 
the  right  cavity  of  the  heart,  or  the  vena  cava,  and  the  other  into  a 
vessel  containing  a  colored  fluid.  He  found  that  with  each  act  of 
inspiration  the  liquid  rose  in  the  tube,  demonstrating  the  effect  of  a 
notable  suction  force.  He  found  that  this  suction  force  was 
increased  by  preventing  the  entrance  of  the  air  into  the  chest 
through  the  trachea.  He  was  of  the  opinion  that  this  force  from  the 
chest  was  exerted  not  only  in  the  large  veins  near  the  heart,  but 
throughout  the  entire  venous  system. 

Schweinburg1  has  studied  the  effect  of  respiration  on  the 
circulation  by  producing  paralysis  of  the  diaphragm  by  section  of 
the  phrenic  nerves.  He  states  that  when  diaphragmatic  respiration 
has  been  artificially  arrested,  the  difference  of  blood  pressure 
observed  during  respiration  entirely  or  nearly  ceases.  From  this  he 
concludes  that  the  action  of  the  diaphragm  causes  to  a  certain  extent 
these  differences.  Even  after  opening  the  abdominal  cavity  the 
difference  in  blood-pressure  is  very  slight.  He  considers  the  com- 
pression of  the  abdominal  vessels  during  inspiration  as  the  principal 
cause  in  abolishing  the  effect  of  respiration  upon  the  circulation, 

1  Die    Bedeutung   der    Zwerchfellcontractionen    ftir   die  respirat.      Blut- 
schwankungen.     Du  Bois-Reymond's  Archiv,  1881,  p.  475. 


INTRAVENOUS  BLOOD   PRESSURE.  211 

causing  the  increase  of  blood  pressure  during  inspiration  and  its 
diminution  during  expiration  by  diminishing  intra-abdominal  com- 
pression. If  the  jugular  vein  in  an  animal  is  exposed,  direct 
observations  show  conclusively  that  the  direct  influence  of  inspira- 
tion cannot  be  felt  much  beyond  these  vessels.  The  flaccidity  of  the 
walls  of  the  veins  will  not  permit  the  extended  action  of  any  suction 
force,  but  the  flow  of  blood  in  the  distant  veins  is  accelerated  by  the 
intermittent  emptying  of  the  veins  by  the  respiratory  act.  Barry 
and  Donders  ascribe  to  the  aspiratory  function  of  the  chest,  the 
principal  motor  in  the  return  of  the  venous  blood.  Donders  esti- 
mated the  aspiratory  force  of  the  inspirator}7  movements  of  the  chest 
at  7  mm.  Hg. 

Clinical  observation  and  experimental  research  have  established 
the  fact  that  the  venous  circulation  is  directly  influenced  by  respira- 
tion within  a  certain  area,  and  that  aspiration  of  air  in  the  majority 
of  cases  takes  place  in  those  veins  so  affected,  thus  constituting  the 
justly  much  dreaded  "  danger-zone."  Instead  of  speaking  of 
the  effect  of  respiration  on  the  veins  as  a  cause  of  aspiration  of  air, 
some  authors  speak  of  the  vein  pulse,  and  limit  the  danger-zone  to 
the  veins  which  ptdsate.  Under  certain  circumstances  the  pulsations 
of  the  arteries  are  communicated  directly  to  the  veins  through  the 
capillaries.  In  such  instances  it  is  necessary  that  the  arterioles  be 
relaxed,  as  has  been  ascertained  by  Bernard  in  observing  the  circu- 
lation in  glands  during  their  physiological  activity.  If  a  vein  be 
opened  in  a  gland  during  its  physiological  activity,  the  blood  partly 
retains  its  arterial  hue  and  escapes  in  intermittent  jets,  as  from  a 
divided  artery.  According  to  recent  physiological  investigations, 
veins  continue  to  pulsate  independently  of  the  arterial  system  and 
the  cerebro-spinal  centers. 

Luchsinger1  examined  the  venous  pulsation  in  the  wings  of 
bats.  Contrary  to  Schiff's  observations  he  found  it  independent  of 
the  central  nervous  system.  Division  of  the  brachial  plexus  and 
separation  of  all  tissue  connections  between  hand  and  body,  with  the 
exception  of  the  vessels,  did  not  arrest  it.  If  artificial  circulation 
was  established  in  the  organ  after  amputation,  rhythmic  venous 
contractions  would  be  seen  even  twenty  hours  after  death.    Intraven- 


1  Von  den  Venenherzen    in    der    Flughaut    der   Fledermause.      Pfluger's 
Archiv,  1881,  vol.  xxvi. 


212  EXPERIMENTAL  SURGERY. 

ous  pressure  was  found  to  be  of  great  importance  in  these  experi- 
ments; as  soon  as  it  was  increased  the  vein  began  to  pulsate.  The 
seat  of  these  rhythmic  contractions  Luchsinger  placed  in  the  walls  of 
the  vessels,  or  rather  in  their  muscular  structures.  They  were 
probably  regulated  by  the  central  nervous  system.  Slight  increase 
of  warmth  and  electric  tetanization  accelerated  the  contractions. 
High  temperature  caused  diastolic  stasis.  Nitrite  of  amyl  increased 
the  pulsating  only  to  arrest  it  later.  Schiff  has  since  satisfied 
himself  that  these  pulsations  continue  after  division  of  the  brachial 
plexus  and  ligature  of  the  vessels,  and  even  in  the  veins  in  detached 
pieces  of  the  bat's  wings. 

Brunton1  has  made  the  same  observations  on  man  in  regard  to 
the  effect  of  increased  intravascular  pressure  in  producing  venous 
pulsations  in  the  larger  veins.  He  finds  that  pulsation  of  the  jugular 
vein  is  sometimes  confined  to  one  side,  the  left  one.  In  one  of  his 
cases  the  jugular  on  the  left  side  was  much  more  distended  than  the 
right  jugular,  the  distention  increasing  whenever  the  vein  was  com- 
pressed just  above  the  clavicle.  Whenever  this  compression  was 
repeated  in  the  rhythm  of  the  pulse,  the  increase  and  decrease 
of  the  blood  in  the  vein  assumed  the  character  of  pulsation,  and  for 
this  reason  the  author  has  arrived  at  the  conclusion  that  the  venous 
pulsation  in  such  cases  is  caused  by  compression  of  the  vena  anonyma 
by  the  aorta.  All  cases  of  unilateral  jugular  pulsation  observed  by 
Brunton  occurred  in  antemic  women.  In  one  of  these  the  pulsation 
took  place  only  while  the  patient  was  affected  by  some  emotional 
excitement,  in  another  only  during  expiration. 

In  rabbits  the  author  has  repeatedly  observed  rhythmical  con- 
tractions of  the  pulmonary  veins,  the  vena  cava  inferior,  and  the 
portal  vein,  occurring  immediately  after  the  death  of  the  animals. 
These  pulsations  were  present  after  complete  cessation  of  the  heart's 
action,  and  sometimes  even  before  death,  and,  as  the  pulsations  were 
more  frequent  than  the  heart's  action,  it  was  plain  that  they  occurred 
independently  of  any  contraction  of  that  organ.  In  consequence  of 
long-continued  pressure  on  a  vein  the  author  has  seen  tonic  contrac- 
tions take  place,  especially  in  smaller  veins,  and  this  may  explain  the 
cause  of  some  of  the  irregularities  of  the  circulation  and  subsequent 
transudation. 

1  On  Pulsations  in  the  Jugulars  and  other  Veins.     Medical  Press  and  Cir- 
cular, July  2,  1879. 


INTRAVENOUS  BLOOD   PRESSURE.  213 

Riegel1  has  made  vein  pulsation  a  special  subject  of  investiga- 
tion, and  as  a  result  of  his  researches  he  has  come  to  the  following 
conclusions:  1.  There  exists  in  the  normal  condition,  a  pulsation  of 
the  jugular  vein.  2.  This  normal  pulsation  is  always  anadicrotic, 
that  is,  its  wave  rises  in  two  distinct  intervals.  The  anadicrotic 
wave  corresponds,  in  contradistinction  to  the  pulsation  of  the 
carotids,  to  the  diastole  of  the  heart.  The  short  catacrotic  line  or 
wave  corresponds  to  the  systole,  the  anacrotic,  to  the  diastole  of  the 
heart.  Synchronously  with  the  systole,  the  contents  of  the  vein  are 
emptied  into  the  heart,  while  during  the  diastole,  stasis  takes  place 
in  the  veins. 

King,2  in  his  interesting  essay  "  On  the  Safety-Valve  Function 
in  the  Right  Ventricle  of  the  Human  Heart,"  demonstrates  the 
existence  of  venous  pulsations  in  the  veins  of  the  hand,  the  median 
veins  of  the  forehead,  and  the  external  jugular,  which  he  observed 
after  a  full  meal.  The  pulsations  were  made  plainly  visible  by 
taking  a  delicate  thread  of  sealing  wax  about  two  inches  in  length, 
one  end  of  which  was  fixed  across  the  vein  with  a  little  tallow  so  as 
to  make  a  long  and  excessively  light  lever,  capable  of  indicating  a 
very  slight  movement  in  the  vessel.  The  movements  of  the  lever 
produced  by  the  vein  pulse  corresponded  in  frequency  with  the  pul- 
sations of  the  arteries  in  the  same  vicinity,  but  did  not  correspond 
in  time,  as  the  venous  pulse  followed  the  arterial  systole,  showing 
conclusively  that  it  was  not  due  to  the  impulse  of  an  adjacent  artery. 
The  pulsations  could  only  be  caused  by  the  arterial  wave  being  con- 
tinued to  the  veins  through  the  capillary  vessels.  In  certain  patho- 
logical conditions  independently  of  valvular  lesion  of  the  heart,  he 
noted  a  marked  increase  in  the  venous  pulsations  in  the  dorsal  veins 
of  the  hand  and  other  vessels  distant  from  the  heart. 

The  subject  of  the  vein  pulse  affords  an  interesting  topic  in 
physiology,  but  in  connection  with  this  paper  it  is  only  mentioned 
in  order  to  show  that  the  intravenous  tension  is  only  slightly  affected 
by  it,  and  that  consequently  it  can  exert  no  direct  influence  in 
causing  aspiration  of  air  into  veins.  The  venous  pulsations  which 
directly  influence  the  return  of  the  vonous  blood  to  the  right  side  of 
the  heart  occur  synchronously  with  the  movements  of  respiration, 

1  Zur  Kenntniss  von  dem  Verhalten  des  Venensystems  unter  normalen 
und  pathologischen  Verhaltnissen.     Berl.  Klin.  Wochenschrift,  No.  18,  1881. 

2  Guy's  Hospital  Reports,  1837,  p.  108. 


214  EXPERIMENTAL  SURGERY. 

and  are  observed  only  in  the  veins  which  are  in  close  proximity  to 
the  heart,  and  in  venous  channels  with  firm  unyielding  walls.  The 
introduction  of  air  can  only  follow  in  wounds  of  vessels  where  -the 
intravascular  pressure  is  subjected  to  great  variations,  either  from 
normal  anatomico-physiological  conditions,  or  as  the  result  of  patho- 
logical alterations.  All  causes  which  prevent  a  prompt  collapse  of 
the  walls  of  a  wounded  vein  must  be  considered  as  predisposing 
causes,  while  all  conditions  which  tend  to  produce  a  vacuum  in  the 
wounded  vein  act  as  determining  causes.  The  location  of  the 
former  corresponds  to  the  point  of  injury,  while  the  latter  are  always 
represented  by  the  aspiratory  action  of  the  chest  during  inspiration. 

V.    Aspiration  of  Air  into  the  Superior  Longitudinal  Sinus. 

Nearly  all  of  the  older  physiologists  were  of  the  opinion  that 
aspiration  of  air  into  veins  could  only  take  place  in  vessels  which 
were  in  close  proximity  to  the  heart  and  within  reach  of  the  venous 
pulse.  Mery  claimed  that  the  effect  of  thoracic  aspiration  on  the 
venous  circulation  extended  to  the  sinuses  of  the  dura  mater  and 
venous  channels  in  the  diploe  of  the  cranial  bones.  Bernard  was 
aware  that  air  might  enter  the  sinuses  in  case  these  structures  were 
wounded,  as  this  accident  ocurred  a  number  of  times  in  his  experi- 
ments on  animals  where  the  superior  longitudinal  sinus  was  opened 
for  other  purposes.  He  believed  that  the  air,  after  entering  the 
sinus,  reaches  the  heart  through  the  vertebral  veins  and  the  vena 
azygos.  Death  in  such  instances  took  place  in  eighteen  minutes, 
while  forty-five  minutes  were  required  if  death  resulted  from  hsernor- 
rhage  alone. 

Volkmann's  case,  reported  in  another  part  of  this  paper,  demon- 
strates to  a  certainty  that  death  may  be  caused  by  the  entrance  of 
air  through  a  wound  of  the  longitudinal  sinus.  Although  this  is 
the  only  authenticated  case  on  record,  similar  cases  have  undoubtedly 
occurred  before,  but  the  real  cause  of  death  was  not  recognized,  and 
the  fatal  result  was  attributed  to  some  other  source.  This  subject 
of  aspiration  of  air  into  the  longitudinal  sinus  was  made  the  object 
of  experimental  inquiry  by  Genzmer,  one  of  Volkmann's  assistants.1 

1  Extirpation  eines  faustgrossen  Fungus  dune  matris,  todtlich  verlaufen 
duroh  Lufteintritt  in  den  geoffneten  Sinus  longitudinalis.  Verh.  d.  deutschen 
Gesellschaft  f.  Chirurgie,  vol.  vi.  p.  32. 


ENTRANCE   OF  AIR   INTO   LONGITUDINAL   SINUS.  215 

The  experiments  were  made  on  dogs,  as  this  vessel  in  rabbits 
was  found  too  small  for  the  operation.  Nine  experiments  were 
made.  The  animals  were  made  partially  insensible  by  morphine 
injections.  The  skull  was  exposed  by  an  incision  which  was  carried 
from  the  occipital  bone  to  the  forehead ;  with  a  small  straight  chisel, 
a  section  of  bone  about  6  cm.  square  was  mapped  out  by  cutting 
through  the  external  table,  anteriorly  to  the  prominentia  occipitalis 
externa,  and  was  completely  detached  with  a  hollow  chisel.  The 
dura  mater  having  thus  been  freely  exposed,  the  posterior  portion 
of  the  longitudinal  sinus,  which  was  about  2  mm.  in  width,  was 
made  accessible  about  its  middle.  The  sinus  was  made  tense  and 
divided  transversely  between  two  small  hooks,  carefully  guarding 
against  injury  to  the  subarachnoidean  space. 

In  some  of  the  experiments  the  wound  was  kept  patent  by 
making  traction  on  its  margins  with  the  hooks,  in  others  this  precau- 
tion was  unnecessary  as  the  edges  of  the  wound  retracted  sufficiently 
to  keep  it  open.  For  several  minutes  after  incision  the  bleeding 
continued  profusely;  the  blood  was  quite  red  and  escaped  with  some 
degree  of  force,  the  pulsations  being  plainly  visible  and  synchronous 
with  the  heart's  action.  The  stream  was  also  perceptibly  increased 
and  diminished  by  the  respiratory  movements  of  the  chest.  After  a 
few  minutes  had  elapsed  the  haemorrhage  became  less  profuse.  In 
case  the  animal  died,  the  heart  and  lungs  were  removed,  after  care- 
fully tying  the  large  vessels  so  as  to  prevent  the  escape  of  air  from 
the  heart. 

To  secure  accuracy  in  ascertaining  the  presence  of  air  in  the 
heart,  this  organ  was  opened  under  water,  when  the  rising  bubbles 
would  indicate  its  presence.  In  two  of  these  cases  the  animal 
breathed  through  a  tracheal  cannula,  the  double  rhythm  in  the  blood 
column  was  lost  soon  after  the  sinus  was  opened,  and  the  blood  con- 
tinued to  flow  until  the  death  of  the  animal,  which  occurred  after 
thirty-five,  forty,  and  fifty  three  minutes,  respectively,  the  stream 
from  the  peripheral  end  of  the  sinus  growing  constantly  less  during 
this  time.  In  all  of  these  cases  the  central  end  of  the  sinus  was 
completely  filled  with  a  thrombus,  and  no  air  was  found  in  the  heart. 
In  two  other  cases  the  double  rhythm  continued  until  life  was  extinct, 
which  was  the  case  after  twelve  and  nineteen  minutes.  After  the 
first  two  or  three  minutes  the  bleeding  diminished,  and.  by  removing 
the  blood  from  time  to  time  with  a  sponge,  it  could  be  seen  how  air 


216  EXPERIMENTAL   SURGERY. 

was  aspirated  during  inspiration  through  the  gaping  wound.  During 
forcible  expiration,  or  on  compressing  the  chest,  air  bubbles  escaped 
with  the  blood  from  the  wound,  from  the  proximal  end  of  the  sinus. 
As  the  bleeding  diminished,  air  aspiration  became  more  copious  and 
more  frequent. 

An  examination  of  the  cadavers  of  these  animals  revealed  that 
the  right  side  of  the  heart  contained  air  and  spumous  blood.  In  the 
next  two  cases  artificial  dyspnoea  was  produced,  in  one  instance  by 
dividing  both  pneumogastric  nerves,  in  the  other  by  closing  the 
tracheal  cannula  through  which  the  animal  was  breathing.  In  the 
first  case  air  entered  early  and  the  animal  died  in  sixteen  minutes; 
in  the  second  case  air  entered  freely  during  the  forcible  inspiratory 
efforts  and  the  animal  died  in  twenty-four  minutes.  In  both  of  these 
cases  air  was  found  in  the  right  side  of  the  heart  and  in  the  sub- 
pleural  vessels.  In  the  last  two  experiments  the  animals  were  killed 
fifteen  and  sixty  minutes  after  the  sinus  was  opened,  by  puncturing 
the  brain  with  a  needle.  In  the  first  case  a  considerable  amount  of 
air  was  found  in  the  right  side  of  the  heart,  and  in  the  second  case 
the  amount  of  air  contained  in  the  right  side  of  the  heart  was  less, 
the  apparent  difference  being  due  to  the  presence  of  a  thrombus  in 
the  central  end  of  the  sinus  in  this  case,  which  prevented  further 
ingress  of  air. 

In  recapitulation  it  may  be  stated  that  in  six  out  of  nine  experi- 
ments, air  entered  the  longitudinal  sinus,  thus  proving  conclusively 
that  wounds  of  this  great  reservoir  of  venous  blood  are  not  only 
dangerous  from  the  loss  of  blood,  thrombosis,  and  inflammation,  but 
may  also  become  the  direct  cause  of  sudden  death  by  admitting  air 
into  the  venous  circulation. 

"VI.    Experiments. 

These  experiments  were  made  by  the  writer  for  the  purpose  of 
ascertaining  more  fully  the  conditions  which  determine  the  entrance 
of  air  into  a  wounded  longitudinal  sinus,  and,  at  the  same  time,  in 
order  to  obtain  reliable  information  concerning  the  prophylactic 
measures  as  well  as  to  determine  the  best  methods  of  arresting  haem- 
orrhage in  wounds  of  this  vessel.  All  operations  were  made  under 
antiseptic  precautions;  when  not  specified  no  anaesthetic  was  used. 
The  field  of  operation  was  cleanly  shaved,  and  the  surface  thoroughly 


EXPERIMENTS.  217 

disinfected  with  a  five  per  cent,  solution  of  carbolic  acid;  during 
the  operations,  frequent  use  was  made  of  the  irrigator,  using  a  warm 
two  per  cent,  solution  of  the  same  antiseptic.  When  the  animal 
survived  the  operation,  the  wound  was  closed  with  continued  catgut 
sutures,  and  dressed  with  iodoform  and  a  compress  of  salicylated 
cotton  retained  by  a  roller  bandage. 

The  operation  consisted  in  making  a  longitudinal  incision  in  the 
median  line  of  the  skull,  reaching  from  the  external  occipital  pro- 
tuberance to  near  the  upper  extremity  of  the  frontal  sinuses.  The 
soft  parts  with  the  periosteum  were  separated  and  reflected  on  each 
side,  so  as  to  lay  bare  the  bone  over  a  sufficiently  large  area  for  the 
ready  use  of  the  bone-cutting  instruments.  A  medium-sized  trephine 
was  applied  over  the  middle  of  the  longitudinal  sinus,  and  the  button 
of  bone  carefully  removed  so  as  to  prevent  injury  of  the  underlying 
vessel.  The  enlargement  of  the  circular  aperture  was  effected  with 
a  hollow  chisel  and  I/ner's  bone- forceps.  The  opening  in  the  bone 
was  made  of  an  oval  or  oblong  shape  with  the  longest  diameter 
parallel  to  the  sinus,  in  order  to  bring  into  view  a  large  extent  of  the 
vessel  with  a  minimum  destruction  of  the  cranial  vault. 

Experiment  1.  Small  Skye  terrier,  weight  twelve  pounds.  Ether  used  as 
an  anaesthetic.  Longitudinal  sinus  laid  bare  to  the  extent  of  one  and  one-half 
inches  by  an  oval  opening  in  the  sknll.  Copious  haemorrhage  from  a  vein 
leading  into  sinus,  which  was  arrested  after  ligature.  Two  catgut  ligatures 
were  placed  underneath  the  sinus,  about  half  an  inch  apart,  and  the  vessel  cut 
transversely  between  them.  The  bleeding  was  very  copious,  the  blood  escap- 
ing in  jets  synchronous  with  the  heart's  impulse;  the  flow  was  also  distinctly 
increased  and  diminished  by  the  respiratory  movements  of  the  chest.  During 
inspiration  the  stream  was  diminished,  while  expiration  was  always  attended 
by  a  decided  increase  in  the  force  of  the  jet  and  the  amount  of  bleeding.  No 
air  wag  seen  to  enter,  although  the  haemorrhage  had  been  very  profuse  and 
continuous  for  a  considerable  length  of  time. 

As  it  was  intended  by  this  experiment  to  prove  that  sudden  obliteration 
of  the  longitudinal  sinus  is  not  incompatible  with  life,  the  distal  ligature  was 
tied  with  the  effect  of  nearly  but  not  completely  arresting  the  haemorrhage,  as 
some  blood  escaped  from  the  proximal  end  of  the  vessel.  It  was  now  expected 
that  air  would  be  more  prone  to  enter  through  the  gaping  wound  in  the  sinus, 
as  the  blood  pressure  from  the  distal  end  of  the  vessel  had  been  arrested  by 
the  ligature,  but  as  this  accident  did  not  take  place  after  a  few  minutes  the 
second  ligature  was  tied,  and  the  wound  in  the  skin  united  with  the  continued 
oatgnl  suture,  and  the  antiseptic  compress  applied.  The  animal  showed  no 
other  symptoms  except  greal  prostration  from  the  sudden  and  profuse  loss  of 
blood.     After  an  hour  it  rallied  and  apparently  was  in  full  possession  of  all  its 


218  EXPERIMENTAL  SURGERY. 

special  senses,  and  was  able  to  walk  about  as  usual.  The  next  day  it  mani- 
fested a  ravenous  appetite,  and,  during  the  whole  time  it  was  kept  under 
observation,  it  showed  no  signs  of  illness  or  discomfort.  The  wound  united  by 
primary  union,  the  skull  showing  the  oblong  bony  defect  at  the  site  of  the 
operation,  through  which  the  pulsations  of  the  brain  could  be  distinctly  seen 
and  felt.  Unfortunately  the  animal  ran  away  after  complete  recovery  had 
taken  place,  and  deprived  me  of  the  opportunity  to  study  by  post-mortem 
examination  the  local  effect  on  the  intracranial  circulation  by  the  operation. 

This  experiment  tends  to  prove  that  ligature  of  the  longitudinal  sinus  can 
be  performed  without  seriously  compromising  the  functions  of  the  brain,  and 
that  in  certain  well-defined  instances,  this  procedure  might  be  resorted  to  in 
practice  with  a  view  of  preventing  or  arresting  haemorrhage  from,  and  the 
entrance  of  air  into,  this  vessel,  in  intentional  or  accidental  wounds  of 
the  sinus. 

Experiment  2.  Small  tan  cur,  weight  ten  pounds.  Partial  ether  anaes- 
thesia. Longitudinal  sinus  opened  by  two  transverse  incisions  in  close 
proximity;  haemorrhage  alarming,  at  first  in  jets,  and,  as  the  bleeding  dimin- 
ished, in  a  more  continuous  flow.  At  first  the  blood  was  bright  red,  but  as 
respiration  became  impaired,  it  grew  darker  in  color.  Dilating  forceps  were 
introduced  into  the  proximal  wound,  the  haemorrhage  continued,  but  no  air 
entered  as  long  as  the  animal  was  in  a  lying  position.  As  the  respiration 
became  more  irregular  and  superficial,  artificial  respiration  was  resorted  to, 
and  the  head  placed  in  an  elevated  position,  whereupon  the  keart  suddenly 
ceased  to  pulsate,  and,  upon  applying  the  ear  to  the  precordial  region,  a  few 
irregular  and  very  feeble  contractions  were  heard,  attended  by  a  distinct 
churning  sound,  when  the  animal  suddenly  expired. 

Before  death,  electricity  was  used  with  the  effect  of  improving  the  respi- 
rations, but  it  had  no  effect  whatever  upon  the  action  of  the  heart.  Death 
took  place  about  three-quarters  of  an  hour  after  the  sinus  was  opened.  At  the 
examination,  immediately  after  death,  all  the  tissues  and  organs  were  found 
in  an  exsanguinated  condition.  All  the  vessels  leading  to  and  from  the  heart 
were  carefully  tied,  and  the  organ  removed.  On  being  placed  in  water  it 
floated  like  a  cork;  the  right  auricle  and  ventricle  were  dilated,  and  on  being 
opened  under  water,  bubbles  of  air  and  only  a  very  slight  amount  of  spumous 
blood  escaped.  The  pulmonary  artery  was  also  distended  with  air.  The  left 
ventricle  was  almost  completely  empty. 

In  this  instance  the  animal  almost  bled  to  death  from  the  wounds  in 
the  longitudinal  sinus,  and  yet  no  air  entered,  although  the  wound  was  kept 
patent  with  a  pair  of  forceps.  The  entrance  of  air  was  caused  by  the  elevation 
of  the  head  and  the  forcible  movements  of  the  chest  during  the  performance 
of  artificial  respiration.  To  judge  from  the  amount  of  air  found  in  the  right 
side  of  the  heart  and  its  effects,  the  air  must  have  entered  quickly  and  in  con- 
siderable quantity,  distending  at  once  the  right  side  of  the  heart  to  such  an 
extent  as  to  paralyze  the  muscles  of  the  heart  in  the  diastole,  after  a  few  feeble 
attempts  to  force  it  from  the  right  chambers.  I  believe,  if  the  animal  had 
been  left  in  the  lying  position,  and  the  head  dependent,  that  death  would  have 


EXPERIMENTS.  219 

taken  place  from  haemorrhage,  as  the  blood  which  was  draining  through  the 
sinus  prevented  the  entrance  of  air.  As  soon  as  the  head  was  raised,  however, 
the  contents  of  the  sinus  flowed  by  gravitation  towards  the  heart,  and  air 
entered  with  it  to  fill  the  vacuum  which  was  being  prepared  by  the  diminished 
blood  supply  to  the  brain,  and  the  acceleration  of  venous  return,  as  well  as 
the  increased  aspiration  of  the  chest,  which  was  brought  about  by  the  attempts 
at  artificial  respiration. 

Experiment  3.  Horse,  about  twelve  years  old.  Partial  chloroform  anaes- 
thesia. Animal  kept  lying  on  the  ground,  the  head  on  a  level  with  the  body. 
Longitudinal  sinus  exposed  for  about  two  inches  and  a  longitudinal  incision 
one  inch  in  length  made.  Haemorrhage  very  profuse;  blood  at  first  bright  red, 
gradually  growing  darker  in  color;  double  wave  well  marked.  After  about 
three  quarts  of  blood  had  been  lost,  as  the  haemorrhage  still  continued  at  the 
same  rate,  and  was  not  readily  controlled  by  the  ordinary  compression,  it  was 
decided  to  implant  an  aseptic  sponge  into  the  sinus.  This  was  done,  and  the 
external  wound  united  over  it  by  the  continuous  suture.  No  air  was  seen  to 
enter  the  wound,  and  auscultation  over  the  heart  revealed  no  abnormal 
sounds.  During  the  operation  of  chiselling,  the  apices  of  the  frontal  sinuses 
were  opened,  which  led  to  the  fear  that  infection  of  the  wound  would  subse- 
quently take  place  from  this  source.  This  expectation  was  realized.  The 
animal  rallied  soon  after  the  operation,  and  appeared  to  be  quite  well  for 
three  days  subsequently,  grazing  in  the  pasture  with  other  horses.  On  the 
morning  of  the  fourth  day  it  was  found  dead. 

Examination  of  the  cadaver  showed  that  the  proximal  end  of  the  sinus 
was  closed  by  a  thrombus  firmly  adherent  to  the  walls  of  the  vessels  and  the 
implanted  sponge,  but  about  the  distal  end  of  the  sponge,  at  a  point  which 
corresponded  to  the  opening  in  the  frontal  sinuses,  the  brain  and  meninges 
showed  all  the  appearances  of  acute  septic  inflammation.  If  infection  had 
not  taken  place  the  aseptic  sponge  would  have  fulfilled  all  the  purposes  for 
which  it  was  intended — arrest  of  haemorrhage  and  obliteration  of  the  sinus. 
It  seems  to  me  that  in  cases  of  uncontrollable  haemorrhage  from  accessible 
venous  sinuses,  the  implantation  of  an  aseptic  sponge  would  prove  a  safe  and 
efficient  measure  against  haemorrhage,  and  would  offer  no  obstacle  to  primary 
union  and  definitive  closure  of  the  vessel,  as  during  the  process  of  granulation 
the  sponge  would  disappear  by  absorption. 

Experiment  4.  Horse,  fourteen  years  old,  in  good  condition.  This 
experiment  was  made  for  the  purpose  of  confirming  the  suspicions  already 
gained  that  the  force  of  gravitation  constitutes  the  most  important  factor  in 
determining  the  admission  of  air  into  an  open  sinus  of  the  dura  mater;  conse- 
quently no  ana-sthetic  was  given,  but  the  animal  was  firmly  held  by  a  bit,  and 
the  operation  was  performed,  without  any  difficulty,  while  the  animal  was  in  a 
standing  position  with  the  head  elevated.  With  the  trephine  and  chisel  an  oval 
opening,  aboul  two  and  a  half  inches  in  extent,  was  made  over  the  longitudinal 
sinus.  After  all  oozing  had  ceased,  the  sinus  being  fully  in  view,  its  anterior 
wall  was  divided  completely  in  a  transverse  direction.  The  edges  of  tli«' 
wound  immediately   retracted,   forming   a   diamond-shaped   opening    through 


220  EXPERIMENTAL   SURGERY. 

which  blood  escaped  in  moderate  force,  but  not  nearly  as  copiously  as  on 
previous  occasions  when  the  animals  were  in  the  lying  position. 

During  the  first  inspiration  after  incision  air  entered  with  a  loud  gurgling 
or  lapping  sound,  and  on  applying  the  ear  over  the  apex  of  the  heart,  a  loud 
churning  sound  was  heard  synchronous  with  the  movements  of  the  heart. 
"During  expiration  air-bubbles  were  seen  to  escape  from  the  proximal  end  of 
the  sinus.  As  soon  as  the  head  was  depressed  the  haemorrhage  greatly 
increased,  but  air  never  entered  in  this  position;  as  soon  as  the  head  was 
elevated,  however,  haemorrhage  either  ceased  entirely  or  was  at  least  greatly 
diminished,  but  air  was  sure  to  enter  during  inspiration.  These  manoeuvres 
were  repeated  a  number  of  times,  and  always  with  the  same  results.  As  the 
amount  of  air  which  was  aspirated  increased,  the  respirations  became  more 
labored,  and  signs  of  cyanosis  became  apparent.  An  attempt  was  now  made  to 
close  the  wound  in  the  sinus  by  sutures,  and  in  this  way  arrest  the  haemorrhage. 
Three  catgut  sutures  were  passed  through  both  edges  of  the  wound,  but  on 
attempting  to  approximate  its  margins  every  one  of  them  tore  through  the 
tissues  before  the  parts  were  in  apposition,  proving  conclusively  that  trans- 
verse wounds  of  the  longitudinal  sinus  cannot  be  sutured,  owing  to  the 
unyielding  nature  of  the  tissues.  The  external  wound  was  completely  closed 
by  the  continuous  suture,  and  a  firm  graduated  antiseptic  compress  controlled 
the  bleeding. 

During  the  whole  time  of  the  operation,  which  lasted  over  an  hour,  some 
one  of  the  bystanders  listened  to  the  heart's  action,  and  the  loud  splashing  or 
churning  sounds  were  constantly  heard.  When  the  animal  was  released  it 
commenced  grazing  in  the  pasture,  and  appeared  as  well  as  before  the  opera- 
tion. The  heart  was  examined  at  intervals  of  thirty  minutes,  and  the  abnormal 
sounds  grew  more  feeble,  and  after  an  hour  had  entirely  disappeared.  The 
sound  produced  by  the  entering  air,  I  have  described  as  lapping,  resembling 
very  much  the  sound  produced  by  the  lapping  of  a  dog  or  cat;  the  best 
possible  word  for  this  sound  is  the  German  expression  "  schluerfend."  When 
air  enters  through  a  wound  of  the  longitudinal  sinus  this  sound  is  character- 
istic, and  is  always  the  same,  and,  in  case  the  animal  operated  upon  is  a  horse, 
it  is  sufficiently  loud  to  be  heard  at  some  distance. 

Experiments  have  shown  that  horses  are  most  tolerant  to  the  presence  of 
air  in  veins,  on  account  of  the  unusual  development  of  the  right  ventricle, 
which  has  sufficient  power  to  force  the  air  through  the  pulmonary  circulation. 
This  experiment  would  certainly  tend  to  corroborate  this  observation,  as  air 
in  large  quantities  was  aspirated  at  least  a  dozen  times  during  the  operation. 
That  most  of  it  entered  the  right  side  of  the  heart,  and  was  not  returned  is 
evident  from  the  persistence  of  the  sounds,  due  to  the  presence  of  air  for  a 
period  of  two  hours;  and  yet,  aside  from  a  certain  degree  of  embarrassment 
of  respiration,  the  animal  suffered  no  inconvenience. 

The  wound  healed  by  primary  union.  The  defect  in  the  skull  remained 
permanent.  The  animal  was  killed  about  four  weeks  afterwards.  Post-mortem 
appearances:  The  trephine  opening  filled  with  cicatricial  tissue.  Proximal 
end  of  sinus,  just  behind  trephine  opening,  contained  one  large  granulation 


EXPERIMENTS.  221 

thrombus.  Cicatricial  tissue  tilled  almost  the  entire  lumen  of  the  sinus. 
Anteriorly  the  sinus  was  somewhat  contracted  and  smooth;  no  thrombus  here 
or  evidences  of  proliferation.  The  circulation  was  apparently  restored  by  the 
formation  of  a  new  channel,  or  dilatation  of  a  pre-existing  one;  this  new  sinus 
was  located  to  the  left  of  the  median  line.  The  lateral  sinuses  were  very  much 
enlarged. 

Experiment  5.  Young  yellow  dog,  weight  about  fifteen  pounds.  Partial 
ether  anaesthesia.  Longitudinal  sinus  exposed  and  transversely  incised  at  two 
points  in  close  proximity.  The  haemorrhage,  which  was  profuse,  was  allowed 
to  continue  for  over  half  an  hour  in  order  to  estimate  the  length  of  time  which 
would  be  necessary  for  death  to  occur  from  this  cause  uncomplicated  by 
admission  of  air.  When  the  animal  appeared  moribund  both  ends  of  the 
sinus  were  ligated.  The  heart's  action  was  very  feeble  and  irregular,  while 
respiration  was  entirely  suspended.  Artificial  respiration  was  kept  up  until 
the  heart's  action  ceased.  Death  occurred  in  thirty-five  minutes.  At  the 
examination  after  death,  no  air  was  found  in  the  vessels  or  heart,  and  death 
was  plainly  attributable  in  the  absence  of  any  other  cause,  solely  to  the  loss 
of  blood. 

Experiment  6.  Newfoundland  dog,  weight  fifty  pounds.  Partial  ether 
narcosis.  During  the  removal  of  bone  over  the  sinus,  severe  haemorrhage  was 
encountered  from  the  large  venous  channels  in  the  diploe.  The  great 
irregularity  of  the  external  surface  of  the  skull  led  to  a  mistake,  as  the  frontal 
sinuses  were  again  opened.  The  longitudinal  sinus  was  laid  open  by  an 
incision  half  an  inch  in  length  in  a  direction  parallel  to  the  vessel.  Haemor- 
rhage very  profuse  for  half  an  hour,  checked  at  times  by  compression,  when  it 
finally  diminished  and  the  wound  was  closed.  After  the  operation  the  animal 
walked  with  a  staggering  gait,  and  would  run  against  objects  indiscriminately 
showing  that  sight  was  greatly  impaired,  inasmuch  as  the  animal  had  fully 
recovered  from  the  effects  of  the  ether.  No  air  was  seen  or  heard  to  enter 
the  sinus.  Heart  sounds  feeble,  but  otherwise  normal.  Death  in  this  case 
took  place  a  week  after  the  operation  from  lepto-meningitis.  The  source  of 
infection  undoubtedly  was  again  traceable  to  injury  of  the  frontal  sinus,  as 
the  earliest  evidences  of  the  disease  were  found  nearest  the  opening  in  this 
structure. 

Experiment  7.  Old  decrepit  horse.  Operation  was  performed  while  the 
animal  was  in  the  erect  position.  On  removing  disc  with  the  trephine  a 
longitudinal  wound  one-half  inch  in  length  was  found  in  the  anterior  wall  of 
the  sinus,  through  which  bright  red  Mood  escaped.  Double  pulsation  well 
marked.  Almost  immediately  after  the  removal  of  the  disc  of  bone,  and 
before  more  than  an  ounce  of  blood  had  escaped,  air  entered  with  a  loud  and 
distinct  Lapping  sound,  audible  to  all  who  were  present.  On  applying  the  ear 
over  the  heart  the  same  loud  churning  sounds  were  heard.  As  the  head  was 
lowered  the  flow  of  blood  became  more  forcible  and  copious,  but  no  air 
entered;  as  soon,  however,  as  the  head  was  elevated,  bleeding  diminished)  and 
air  entered  during  almost  every  inspiration.     Respiration   became   labored, 


222  EXPERIMENTAL   SURGERY. 

and  after  air  had  entered  four  or  five  different  times  in  succession,  the  animal 
fell  to  the  ground. 

In  this  "position  no  further  entrance  of  air  occurred,  but  the  haemorrhage 
continued  copiously,  the  blood  flowing  in  a  continuous  stream  with  a  well- 
marked  double  jet  synchronous  with  the  action  of  the  heart  and  the  respira- 
tory movements  of  the  chest.  The  opening  in  the  skull  was  enlarged  to  two 
inches  in  length  and  one  and  one-half  inches  in  width,  so  as  to  expose  the 
sinus  freely.  A  number  of  catgut  sutures  were  now  introduced  through  both 
lips  of  the  wound,  and  on  attempting  to  tie  them  great  difficulty  was  experi- 
enced in  approximating  its  margins,  which  could  not  be  brought  completely 
in  contact  without  the  sutures  tearing  through.  The  tying  of  all  the  sutures 
resulted  in  diminishing  but  not  arresting  the  bleeding,  showing  conclusively 
that  in  longitudinal  wounds  of  the  sinus,  suturing  is  an  imperfect  and  unre- 
liable measure  in  arresting  haemorrhage,  to  say  nothing  of  the  difficulty  which 
is  experienced  in  passing  the  sutures  at  such  great  depths  and  in  the  limited 
space  furnished  by  the  artificial  opening  in  the  skull. 

The  wound  was  not  closed  but  tamponed  with  iodoform  cotton  in  order 
to  observe  from  time  to  time  the  processes  which  nature  would  initiate  in  the 
restoration  of  the  wounded  sinus.  Half  an  hour  after  the  first  entrance  of  air 
the  churning  sounds  in  the  heart  had  much  diminished,  and  almost  completely 
disappeared  after  the  lapse  of  one  hour.  The  animal  recovered  completely 
from  the  immediate  effects  of  the  air-embolism,  the  respiration  having  again 
become  normal  in  frequency  and  character.  After  two  hours  the  tampon  was 
removed,  but  bleeding  again  occurred,  and  it  was  replaced.  The  animal  died 
twenty-four  hours  after  the  operation,  probably  from  the  combined  effect  of 
loss  of  blood,  haemorrhage  into  the  subdural  spaces,  air-embolism  and  senile 
marasmus.  At  the  examination  of  the  cadaver  a  subdural  clot,  which  weighed 
about  half  an  ounce,  was  found  on  the  right  side  of  the  brain;  on  the  left  side 
of  the  sinus  a  second  but  smaller  subdural  clot  was  found.  Trephine  opening 
filled  by  acoagulum.  One  of  the  sutures  had  lost  its  hold  by  tearing  through 
the  tissues  of  one  margin  of  the  wound.  Within  the  sinus  a  small  fragile  clot 
was  found  in  the  lateral  wall  of  the  sinus  which  served  as  the  source  of  haem- 
orrhage into  the  subdural  space. 

This  experiment  well  illustrates  the  danger  of  plugging  the  opening  in 
the  skull  for  the  purpose  of  arresting  haemorrhage  in  case  the  lateral  walls  of 
the  sinus  aie  injured,  as  it  will  almost  necessarily  lead  to  subdural  haemorrhage, 
and  expose  the  patient  to  all  the  disastrous  consequences  incident  to  this 
occurrence.  In  this  instance  sponge  implantation  would  not  only  have  more 
successfully  guarded  against  external  bleeding,  but  would  also  have  served  as 
a  sure  prophylactic  against  extravasation  into  the  subdural  space.  It  also 
teaches  that  suturing  in  cases  of  wounds  of  the  longitudinal  sinus  with  limited 
defects  in  the  bony  walls  of  the  cranium  is  impracticable,  unreliable,  and 
unsafe,  and  should  never  be  resorted  to  unless  the  dura  mater  is  so  extensively 
exposed  or  separated  as  to  permit,  by  making  gentle  traction,  perfect  and 
■complete  approximation  of  the  margins  of  the  wound. 


PRACTICAL   SUGGESTIONS.  223 

Til.  Practical  Suggestions. 

In  order  to  study  the  conditions  which  favor  the  aspiration  of 
air  into  a  wounded  sinus  of  the  brain  it  is  necessary  to  call  attention 
to  some  of  the  peculiarities  of  the  intra-cranial  circulation.  Mosso,1 
who  has  made  this  a  special  subject  of  investigation,  asserts  that  the 
intravascular  pressure  in  the  veins  within  the  cranium  is  higher  than 
in  the  veins  of  any  other  part  of  the  body.  Actual  measurements 
have  shown  that  the  blood-pressure  in  the  longitudinal  sinus  is  equal 
to  100-110  mm.  Hg.  The  probable  cause  of  this  phenomenon  is 
that  the  force  of  distention  of  the  arteries  within  the  closed  and 
unyielding  cranial  cavity  is  added  to  the  vis  a  tergo.  The  intra-cranial 
veins  show  distinct  pulsations  which  are  dependent  upon  the  pulsa- 
tions of  the  arteries,  and  their  movements  are  so  plain  that  they 
can  be  graphically  demonstrated;  every  diastolic  movement  in  the 
artery  corresponds  to  a  venous  pulse.  During  the  pulsations  of  the 
brain,  Mosso  claims  with  Donders  and  Berlin,  that  the  cerebro-spinal 
fluid  does  not  escape  into  the  spinal  canal.  In  a  case  of  spina  bifida 
he  has  been  able  to  trace  respiratory  but  no  circulatory  movements. 
When  the  tumor  was  compressed  only  a  very  slight  increase  in  the 
volume  of  the  brain  could  be  detected  at  the  fontanelle,  even  if 
nearly  the  whole  contents  of  the  tumor  were  pressed  into  the  spinal 
canal. 

G.  Burkkart2  has  published  the  results  of  his  observations  on 
the  movements  of  the  brain  which  he  made  on  four  patients  who 
had  suffered  partial  loss  of  the  cranial  vault.  The  tracings  ob- 
tained represented  three  forms  of  movements — pulsatile,  respiratory, 
and  vascular.  The  cerebral  pulsation  has  the  form  of  a  tricrotic  or 
tetracrotic  pulse,  the  phases  following  one  another  in  about  the  same 
time  as  those  of  the  carotid  pulse.  His  observations  lead  him  to  the 
conclusion  that  the  brain  presents  the  same  movements  within  the 
intact  skull  as  in  the  infant  or  when  a  defect  in  the  skull  exists,  the 
result  of  traumatism.  The  brain  expansion  is  synchronous  with 
the  dilatation  of  the  vessels  and  takes  place  in  the  direction  of 
the  vascular  ramifications.  The  resistance  is  in  inverse  proportion 
to  this  expansion. 

In  the  closed  skull  the  excess  of  pressure  in  the  arteries  materi 

1  Ueber  den  Kreislauf  des  Blutes  im  menschlichen  Gehirn,  1881. 

2  The  Lancet,  Oct.  15, 1881. 


224  EXPERIMENTAL   SURGERY. 

ally  aids  the  propulsion  «of  the  blood  through  the  veins,  and  also 
that  of  the  sero-lymphatic  fluid.  In  the  open  skull  the  curve  rises 
during  expiration  and  falls  during  inspiration.  All  actions  which 
increase  the  respiratory  movements  increase  the  height  of  the  curve. 
A  secondary  elevation  follows  labored  inspiratory  movements,  but 
the  pulse  waves  are  never  completely  effaced.  The  vascular  curves 
occur  independently  of  respiration  or  pulsation.  The  height  of  the 
curves  bears  no  constant  relation  to  their  length.  They  are  notably 
affected  by  psychical  influences.  They  are  produced  by  move- 
ments of  the  vessels  by  means  of  the  vaso-motor  nerves,  and  can  be 
made  very  conspicuous  by  irritation  of  the  cervical  sympathetic. 

Bergmann,1  in  his  remarks  on  the  movements  of  the  brain  (in 
opposition  to  Mosso)  at  the  meeting  of  the  Congress  of  German 
Surgeons  in  1881,  insisted  that  the  cerebro -spinal  fluid  acts  as  a 
regulator  in  maintaining  the  equilibrium  between  the  arterial  and 
venous  circulation  within  the  cranium.  The  pulsations  of  the 
sinuses  of  the  dura  mater  were  discovered  and  studied  under  his 
supervision  at  Dorpat  as  early  as  1873.  He  argues  that  these  pulsa- 
tions are  very  slight,  and  on  that  account  insufficient  to  counterbal- 
ance the  arterial  pulsations.  He  explains  the  pulsations  of  the 
sinuses  in  the  same  way  that  Donders  and  Jacobi  have  accounted 
for  the  pulsations  in  the  veins  of  the  papilla  of  the  optic  nerve. 
The  pulsations  are  the  result  of  increased  tension  in  the  cerebro- 
spinal fluid  during  the  arterial  systole,  and  the  consecutive  dimin- 
ution of  intracranial  pressure  during  the  arterial  diastole. 

The  cranium  being  a  closed  cavity  with  unyielding  walls,  it  is 
not  difficult  to  understand  that  in  case  one  of  the  sinuses  is  opened 
by  a  wound  which  communicates  with  the  atmospheric  air,  the  sud- 
den loss  of  blood  will  have  a  tendency  to  create  a  vacuum  which  is 
filled  by  the  admission  of  air  which  reaches  the  left  side  of  the  heart 
with  the  venous  blood.  All  circumstances  which  diminish  intravas- 
cular and  intracranial  pressure  must  of  necessity  favor  the  occur- 
rence of  aspiration  of  air  into  a  wounded  sinus.  It  is  evident  that 
aspiration  of  air  into  an  open  wound  of  the  longitudinal  or  any  other 
sinus  of  the  dura  mater  is  favored  by  the  following  conditions:  1. 
The  force  of  gravitation.  2.  The  inspiratory  movements  of  the 
chest.     3.  The  condition  of  arterial  circulation.     In  considering  the 

1  Verhandlungen  d.  deutschen  Gesellschaf  t  f .  Chirurgie,  vol.  x.  p.  14. 


PRACTICAL   SUGGESTIONS.  225 

prophylactic  treatment  against  the  admission  of  air  during  opera- 
tions which  involve  any  of  the  cerebral  sinuses,  it  is  of  the  greatest 
importance  to  keep  the  head  at  a  level  with  the  heart  to  insure  regu- 
lar respiration  and  to  guard  against  undue  or  forcible  inspiration 
and.  finally,  to  maintain  the  normal  activity  of  the  ventricular  con- 
tractions. The  direct  preventive  measures  consist  in:  1.  Continu- 
ous irrigation  of  the  field  of  operation.  2.  Prophylactic  ligation  of 
the  sinus. 

In  resorting  to  constant  irrigation  the  fluid  used  should  be  an 
aseptic  solution  at  the  temperature  of  the  body,  which,  if  it  should 
enter  the  venous  circulation  to  till  an  empty  space,  would  do  no 
harm  either  as  a  toxic  agent  or  by  causing  coagulation  of  the  blood. 
A  solution  of  salicylic  acid  in  distilled  water,  or  borated  water  would 
be  best  adapted  for  this  purpose.  In  extirpating  tumors  of  the 
dura  mater  in  the  region  of  the  longitudinal  sinus,  where  wounding 
of  this  structure  becomes  a  necessity,  it  would  not  only  be  prudent 
but  good  practice  to  ligate  the  sinus  on  each  side  before  attempting 
the  removal  of  the  tumor,  as  this  precaution  would  surely  and 
effectually  prevent  the  two  most  dangerous  and  alarming  accidents — 
hemorrhage  and  aspiration  of  air.  This  plan  was  followed  by 
Kuester  in  removing  a  sarcoma  of  the  dura  mater  in  1881. : 

Experiments  on  animals  and  the  cadaver  have  convinced  me 
that  this  operation  can  be  performed  with  comparative  ease,  if  the 
defect  in  the  skull  is  sufficient  in  extent  to  permit  the  necessary 
manipulations,  and,  in  the  event  this  operation  be  done  for  the 
purpose  of  facilitating  the  removal  of  tumors  of  the  dura  mater, 
this  precaution  should  never  be  neglected.  With  a  tenaculum  the 
dura  mater  should  be  seized  and  drawn  forward  at  the  outer  border 
of  the  longitudinal  sinus,  and  a  small  incision  parallel  with  the 
border  of  the  sinus  made  with  a  tenotome,  the  incision  being  only 
sufficiently  deep  to  divide  the  dura  mater.  After  making  such 
incisions  on  each  side  of  the  sinus  directly  opposite  each  other,  the 
sinus  should  be  grasped  with  a  sharp-toothed  spring-forceps  and 
drawn  forward,  a  small  curved  sharp-pointed  aneurism  needle  passed 
into  one  of  the  openings,  and,  after  penetrating  the  falx  cerebri 
underneath  the  vessel,  brought  out  through  the  opening  on  the 
opposite  side. 

'Berl.  Kim.  Wochenschrif t,  1881,  p.  678. 

15 


226  EXPERIMENTAL  SURGERY. 

When  both  of  the  ligatures  are  in  place  the  peripheral  ligature 
is  tied  first,  and  after  emptying  the  intervening  part  of  the  vessel 
of  its  contents,  the  proximal  ligature  is  also  tied.  If  both  of  the 
ligatures  have  been  properly  applied,  the  intervening  portion  of  the 
sinus  can  be  opened  or  excised  with  the  tumor  without  risk  of  haem- 
orrhage or  the  introduction  of  air;  at  the  same  time  it  will  greatly 
facilitate  thoroughness  in  the  removal  of  diseased  tissue.  I  am 
firmly  convinced  that  the  preliminary  ligation  of  the  longitudinal 
sinus  will  become  an  established  procedure  in  all  cases  where  tumors 
of  the  dura  mater  are  so  situated  that  their  removal  implicates  this 
structure,  and  that  it  will  render  possible  the  removal  of  tumors 
which  without  it  would  place  the  life  of  the  patient  in  great  and 
immediate  jeopardy  by  haemorrhage  or  the  admission  of  air.  The 
process  of  cicatrization  in  the  sinus  is  the  same  as  in  veins,  and 
is  accomplished  in  the  same  brief  period  of  time.  In  accidental 
wounds  of  the  sinus,  ligation  should  be  resorted  to  whenever  the 
orginal  defect  in  the  skull  is  sufficient  to  permit  the  necessary  manip- 
ulations, or  when  simpler  measures  have  failed  to  accomplish  the 
same  object. 

Implantation  of  an  aseptic  sponge  into  a  wounded  sinus  should 
be  resorted  to  in  all  cases  of  wounds  of  the  lateral  walls  of  the  sinus, 
in  cases  of  accidental  wounds  where  ligation  is  impossible  and  where 
other  measures  have  failed  to  arrest  the  haemorrhage.  The  sponge 
should  be  large  enough  to  make  gentle  pressure  upon  the  inner 
surfaces  of  the  sinus,  and  yet  sufficiently  firm  to  arrest  the  circula- 
tion in  the  vessel  so  as  to  prevent  the  escape  of  blood  into  the  sub- 
dural space.  The  haemostatic  action  of  the  aseptic  tampon  is  made 
more  efficient  by  adding  external  compression,  applied  in  the  form 
of  a  graduated  aseptic  tampon.  If  the  wound  remains  aseptic  the 
sponge  forms  a  nucleus  for  the  thrombus  and  is  infiltrated  by  con- 
nective-tissue cells  from  the  intima  and  adjacent  tissues,  and  is 
gradually  removed  by  absorption  as  the  definitive  obliteration  of  the 
vessel  proceeds.  Small  wounds  of  the  sinus  can  be  readily  and 
safely  closed  with  the  lateral  ligature  applied  in  the  same  manner  as 
in  similar  wounds  of  the  veins. 

In  recapitulation  we  are  warranted  in  stating  the  following 
conclusions : 

1 .     Elevation  of  the  head  is  the  direct  and  most  essential  cause 


IMMEDIATE  CAUSE   OF  DEATH.  227 

in  the  production  of  air- embolism  through  a  wound  of  the  superior 
longitudinal  sinus. 

2.  Suturing  of  a  wound  of  the  superior  longitudinal  sinus  as  a 
haemostatic  procedure  is  unreliable,  and  in  most  instances  anatomic- 
ally impossible. 

3.  Prophylactic  ligation  of  the  superior  longitudinal  sinus 
should  be  resorted  to  in  all  cases  where  this  vessel  is  involved,  in 
extirpating  tumors  of  the  dura  mater. 

4.  Implantation  of  an  aseptic  sponge  into  a  wounded  longi- 
tudinal sinus  will  arrest  haemorrhage  without  interfering  with  the 
definitive  obliteration  of  the  vessel,  and  deserves  a  trial  in  cases 
where  the  lateral  walls  of  the  sinus  have  suffered  injury  and  where 
ligation  is  impracticable. 

Till.  Immediate  Cause  of  Death  after  Intravenous 
Insufflation  of  Air. 

Various  theories  have  been  advanced  to  explain  the  injurious 
effect  of  the  presence  of  air  in  the  circulation.  Bichat1  attributed 
death  resulting  from  intravenous  injection  of  air  to  cerebral  anaemia 
produced  by  the  presence  of  air  in  the  cerebral  vessels,  asserting  at 
the  same  time  that  a  very  small  quantity  would  suffice  to  produce 
this  effect.  As  the  first  argument  in  favor  of  this  view,  he  claims 
that  the  heart  continues  to  beat  for  some  time  after  the  cessation  of 
animal  life.  Secondly,  air  injected  through  one  of  the  carotids 
produces  death  in  the  same  way  as  when  introduced  into  the  veins. 
Thirdly,  the  cases  reported  by  Morgagni,  where  death  was  attributed 
to  the  presence  of  air  which  was  found  in  the  cerebral  vessels  at  the 
post-mortem  examination,  and  which  was  supposed  to  have  devel- 
oped there  spontaneoiisly.  Fourthly,  all  examinations  after  death 
revealed  the  presence  of  frothy  blood  mixed  with  air-bubbles,  in 
both  ventricles.  Fifthly,  air  injected  into  one  of  the  divisions  of  the 
portal  vein  produces  no  ill-effects  until  it  reaches  the  general  circu- 
lation. Sixthly,  the  almost  instantaneous  death  observed  in  some 
instances  is  due  to  the  acceleration  of  the  heart's  action,  and  conse- 
quently the  rapid  conveyance  of  air  into  the  cerebral  vessels. 
Seventhly,  the  existence  of  convulsions,  which  he  ascribes  to  the  irri 
fating  ■piality  of  the  air  on  the  brain.     He  summarizes  as  follows: 

1  Physiological  Researches  on  Life  and  Death,  p.  18fi. 


228  EXPERIMENTAL   SURGERY. 

"  We  shall  conclude  that  in  the  accidental  mixture  of  air  with  the 
blood  of  the  venous  system,  it  is  the  brain  which  dies  the  first,  and 
that  the  death  of  the  heart  is  the  consequence  of  the  death  of  the 
brain." 

Magendie,  in  commenting  on  Bichat's  views  concerning  the 
manner  of  death  from  intravenous  injection  of  air,  remarks:  "This 
is  not  correct,  and  death  takes  place,  on  the  contrary,  by  the  cessa- 
tion of  the  motions  of  the  heart.  The  right  ventricle  is  filled  with 
air,  and  this  air,  dilated  by  heat,  so  distends  it  that  it  can  no  longer 
contract."  Magendie  also  claimed  that  small  quantities  of  air  in 
veins  will  not  result  in  death,  and  that  life  is  in  jeopardy  only  when 
the  air  is  injected  suddenly  and  in  considerable  quantity.  He 
relates  the  details  of  an  experiment  which  he  made  on  a  horse,  where 
he  injected  in  rapid  succession  into  the  veins  of  the  animal  forty 
syringefuls  of  air,  and  three  syringefuls  into  the  carotid  artery. 
The  capacity  of  the  syringe  was  seventeen  centilitres.  The  animal 
died  three  minutes  after  the  last  injection.  At  the  examination  of 
the  body  he  found  air  in  the  azygos  vein  and  in  the  thoracic  duct 
which  contained  much  lymph,  as  well  as  in  the  lymphatic  vessels  of 
the  internal  surface  of  the  lungs.  The  heart  was  enormously  dis- 
tended with  air  mixed  with  a  small  quantity  of  blood. 

Morgagni,  Brunner,  Sprcegel,  and  Nysten  referred  the  cause  of 
death  to  the  same  source — over- distention  and  paralysis  of  the  heart. 
When  death  was  not  produced  by  the  mechanical  effect  of  the  air 
on  the  heart,  then  the  consecutive  symptoms  were  referred  by 
Nysten  to  an  obstruction  of  the  lungs  produced  by  the  accumulation 
of  air  in  the  ultimate  divisions  of  the  pulmonary  artery.  He  ob- 
served that  the  embarrassment  in  respiration  often  appears  as  late 
as  twelve  hours  after  the  introduction  of  the  air,  and  becomes 
greater  and  greater;  the  bronchi  are  filled  with  a  viscid  fluid,  and 
the  animal  usually  dies  on  the  third  or  fourth  day.  In  such  in- 
stances no  air  was  found  in  the  heart  or  the  vessels,  but  the  lungs, 
instead  of  being  pink-colored,  were  grayish,  tinged  with  brown,  and 
loaded  with  frothy  blood  and  mucus.  The  same  views  were  enter- 
tained by  Boerhaave,  Kettler,  and  Beck.  In  such  cases  death 
results  from  asphyxia  from  the  mechanical  obstruction  to  the  passage 
of  the  venous  blood  through  the  pulmonary  circulation. 

Mery  accepts  the  views  of  Mercier  published  in  1839,  who 
attributed  death  to  the  fact  that  the  blood  mixed  with  air  becomes 


IMMEDIATE    CAUSE    OF  DEATH.  229 

frothy,  enters  the  pulmonary  capillaries  and  obstructs  them.  Physi- 
cist? are  aware  that  a  capillary  tube  which  readily  admits  the  pas- 
sage of  air  or  water  offers  a  great  resistance  to  a  mixture  of  air  and 
water:  this  mixture  causes  a  series  of  bubbles,  separated  by  minute 
septa  of  liquid.  Poisenille  has  shown  by  a  series  of  experiments 
that  such  in  fact  is  the  cause  of  death  whenever  air  mixed  with  blood 
has  obstructed  the  pulmonary  capillaries.  The  right  heart  remains 
over-distended  and  cannot  be  emptied. 

Blundel '  studied  the  effects  of  the  intravenous  injection  of  air 
in  his  experiments  on  transfusion  of  blood.  He  injected  five 
drachms  of  atmospheric  air  into  the  femoral  vein  of  a  small  dog  in 
quantities  of  a  drachm  each  at  a  time,  without  any  serious  effects. 
The  symptoms  observed  were  sighing  respiration,  irregular  pulse, 
muscular  tremors,  and  vomiting,  all  of  which,  however,  subsided 
after  a  brief  space  of  time,  and  the  animal  recovered  completely  in 
three  days.  A  second  experiment  was  made  on  the  same  animal  by 
blowing  three  drachms  of  pulmonary  air  into  the  femoral  vein  with- 
out even  producing  much  temporary  inconvenience.  He  concluded 
that  it  seemed  indisputable  that  small  quantities  of  air  may  be  intro- 
duced into  the  circulation  without  destroying  life.  Dr.  Haighton 
made  the  same  experiments  with  intravenous  injections  of  air,  and 
with  like  results. 

A  series  of  experiments  were  made  by  Panum.J  In  the  first 
experiment  five  cubic  centimeters  of  air  were  injected  into  the  lower 
portion  of  the  jugular  vein  of  a  small  dog.  No  symptoms  followed 
immediately  after  the  operation.  Four  days  subsequently  the  weight 
of  the  animal  was  reduced  from  3540  to  3030  grammes.  The  tissues 
around  the  point  of  puncture  were  inflamed.  On  the  fifth  day  the 
animal  was  killed.  The  skin  of  the  animal  was  dotted  with  spots  of 
ecchymosis  resembling  the  extravasations  as  they  occur  in  the  disease 
known  as  morbus  maculosus  Werlhofii.  In  the  vicinity  of  the 
wound,  tin-  tisMics  were  emphysematous,  emitting  an  offensive  odor. 
Among  other  post-mortem  appearances  the  lungs  presented  several 
gray  superficial  stripes  and  spots,  one  to  two  lines  in  diameter.  In 
the  middle  of  several  of  these  patches  were  found  empty  spaces 
which  Panum  regarded  as  encysted  air-bubbles.     In  addition,  small 


iledico-Chir.  Trans.,  vol.  ix.  p.  65. 

2 Ex |M-ii iinni 'Hi-  Ueitriitro,  zur  Lehre  von  der  Embolie.     Virohow'a  Arcdiv, 
vo\.  v.  p.  199. 


230  EXPERIMENTAL  SURGERY. 

isolated  nodules  were  also  found  which  contained  in  their  interior 
small  bubbles  of  air.  These  nodules  contained  also  numerous  nuclei 
and  fat  globules. 

In  the  second  experiment  ten  cubic  centimeters  of  air  were 
injected  into  the  lower  portion  of  the  jugular  vein  of  a  small  one- 
year-old  dog.  During  the  first  three  days  nothing  was  observed 
with  the  exception  of  rapid  emaciation.  On  the  fourth  day  the 
animal  began  to  lose  hair  not  only  in  the  vicinity  of  the  wound,  as 
in  the  first  case,  but  over  the  entire  surface  of  the  body.  Later 
inflammation  and  ulceration  attacked  the  point  of  operation.  On 
the  eleventh  day  the  animal  was  killed.  The  lungs  again  presented 
subpleural  nodules,  from  the  size  of  a  pin's  head  to  that  of  a  grain 
of  sand,  in  which  could  be  found  large  cells  filled  with  fat  molecules, 
granular  cells,  and  fat  globules  in  large  number.  Air  could  not  be 
found  in  any  of  them,  and  their  relation  to  the  capillaries  of  the 
pulmonary  artery  could  not  be  determined. 

In  the  third  experiment  thirty  cubic  centimeters  of  air  were 
injected  into  the  jugular  vein  without  producing  any  alarming  symp- 
toms, except  rapid  and  deep  respiration.  The  next  day  no  change 
was  observed,  but  on  the  following  day  the  animal  was  found  dead. 
A  careful  examination  revealed  punctiform  extravasations  in  differ- 
ent portions  of  the  brain,  stomach,  and  liver.  The  wound  showed  a 
healthy  appearance.  The  lungs  contained  many  very  small  yellow- 
ish-white nodules  and  points  of  extravasation  one  to  two  lines  in 
diameter.  The  haemorrhage  infarcts  contained  each  a  minute  cavity 
filled  with  air.  The  nodules  also  contained  air.  From  these  experi- 
ments it  appears  that  the  air -emboli  which  passed  through  the 
pulmonary  capillaries  produced  local  disturbances  in  the  minute 
vessels  in  the  skin  and  gastro-intestinal  canal,  while  the  air-emboli 
in  the  ultimate  branches  of  the  pulmonary  artery  gave  rise  to  cir- 
cumscribed foci  of  inflammation. 

Picard1  found  after  insufflation  of  air  into  the  portal  vein, 
intense  hyperemia  in  the  distal  portion  and  radicles  of  the  vessel, 
the  same  as  after  ligation.  At  the  commencement  of  the  insufflation 
the  blood  pressure  in  the  femoral  artery  and  one  of  the  rectal  veins 
was  about  the  same;  after  a  while  the  pressure  in  both  was  simul- 

1  Sur  les  injections  d'air  dans  la  veine  porte.  Gazette  Medicale  de  Paris, 
No.  6,  1873. 


IMMEDIATE    CAUSE    OF  DEATH.  '231 

taneously  diminished,  but  the  positive  pressure  lasted  longer  in  the 
vein  than  in  the  artery.  The  action  of  the  heart  was  increased,  the 
respirations  became  slower,  and  the  temperature  in  the  rectum  was 
gradually  reduced.  As  an  interesting  physiological  fact  it  is  men 
tioned  that  after  insufflation  of  air  into  the  portal  vein  no  sugar 
could  be  found  in  the  liver,  and  the  fibrin  in  the  portal  blood  was 
diminished.  ■ 

The  experiments  of  Magendie,  Bouillaud,  and  later  those  of 
Couty,1  prove  conclusively  that  in  cases  of  entrance  of  air  into  a 
peripheral  vein  the  air  collects  almost  exclusively  in  the  right  side  of 
the  heart,  only  a  minute  quantity  entering  the  left  side  through  the 
pulmonary  capillaries.  Referring  to  this  question  Flint  says:  "The 
production  of  death  from  air  in  the  veins  is  purely  mechanical.  The 
air,  finding  its  way  to  the  right  ventricle,  is  mixed  with  the  blood  in 
the  form  of  minute  bubbles  and  passed  into  the  plumonary  artery. 
Once  in  this  vessel,  it  is  impossible  for  it  to  pass  through  the  capil- 
laries of  the  lungs,  and  death  by  suffocation  is  the  inevitable  result 
if  the  quantity  of  air  be  large.  It  is  because  no  blood  can  pass 
through  the  lungs  that  the  left  cavities  of  the  heart  are  usually 
found  empty."  " 

If  the  quantity  of  air  introduced  is  small,  or  the  entrance 
repeated  in  small  quantities,  the  air  collects  in  the  capillaries  of  the 
pulmonary  artery  as  air-emboli,  obstructing  the  circulation  in  the 
impacted  vessels;  but  a  sufficient  number  of  vessels  remain  pervious 
to  maintain  the  circulation,  and  life  is  prolonged  until  the  equilibrium 
of  the  circulation  is  restored  by  the  absorption  of  the  adventitious 
air.  No  traces  of  air  are  found  in  the  arteries,  only  a  small  quantity 
passing  into  the  venre  cawe  through  the  tricuspid  valve,  which  has 
been  rendered  insufficient  by  the  presence  of  air.  When  a  consider- 
able amount  of  air  has  entered  the  right  ventricle  of  the  heart 
mixed  with  the  blood,  the  air  is  separated  from  it,  and,  its  specific 
gravity  being  less,  it  rises  to  the  highest  point  of  the  chamber  in 
contact  with  the  anterior  walls.  It  also  expands,  and  by  this  over- 
distention  it  impairs  the  muscular  contractility  which  even  in  a 
normal  condition  is  insufficient  to  completely  empty  the  cavity. 

The  impediment  to  the  circulation  being  the  presence  <;f  the 


Kt  ade  experimental  sw  l'entr6e  de  l'air  dans  les  veines,  Paris,  L875. 
*  Physiology  of  Man,  Blood,  Circulation,  Respiration,  p.  328,  1866. 


232  EXPERIMENTAL   SURGERY. 

large  air- embolus  in  the  right  ventricle,  which  on  account  of  the 
higher  temperature  increases  in  volume,  sudden  death  will  take  place 
in  the  diastole  by  an  arrest  of  the  heart's  action  from  paralysis  by 
over-distention.  If  the  animal  escapes  instantaneous  death  from 
this  cause,  the  heart  is  inadequate  to  force  the  blood  from  the  right 
ventricle  through  the  pulmonary  circulation,  as  its  efforts  are 
expended  in  compressing  the  air;  only  a  minute  quantity  of  blood 
being  forced  into  the  lungs.  In  proportion  as  the  amount  of  air  and 
blood  in  the  right  ventricle  increases,  the  right  side  of  the  heart  is 
expanded  and  the  volume  of  blood  in  the  lungs  and  the  left  heart  is 
diminished.  At  last  the  distended  walls  of  the  heart  prevent  perfect 
closure  of  the  tricuspid  valve,  giving  rise  to  venous  pulsation,  a 
constant  symptom  in  all  cases  of  air-embolism  which  prove  rapidly 
fatal.  On  the  advent  of  this  complication  the  intra-arterial  pressure 
in  the  pulmonary  and  peripheral  arteries  diminishes,  which  further 
enfeebles  the  pulmonary  circulation;  at  the  same  time  it  produces 
acute  anaemia  of  the  brain,  and  death  results  from  ana9mia  of  the 
brain  or  asphyxia. 

Such  is  the  mechanism  of  death  in  cases  of  entrance  of  air  into 
the  venous  circulation;  it  also  offers  an  explanation  why  in  these 
cases  the  air  is  found  mostly  in  the  right  side  of  the  heart  and  the 
large  venous  trunks.  These  facts  also  corroborate  the  observations 
of  experimenters  that  certain  animals  succumb  more  readily  to  the 
presence  of  air  in  veins  than  others.  The  tolerance  of  intravenous 
air  is  most  marked  in  animals  with  well -developed  respiratory  organs 
and  a  proportionately  powerful  right  ventricle.  In  horses,  for 
example,  the  volume  of  the  right  cavities  is  smaller  and  the  muscular 
structure  more  powerful,  circumstances  which  explain  the  fact  that 
entrance  of  air  into  the  veins  of  these  animals  does  not  easily  kill 
them.  The  circulatory  apparatus  of  the  dog  offers  the  least  resist- 
ance to  intravenous  air.  Key  blew  air  into  the  jugular  veins  of 
horses  after  venesection  without  producing  death.  Small  amounts 
of  air  produced  no  result  whatever,  and  a  volume  of  air  equivalent 
to  two  expirations  proved  fatal  only  in  debilitated  animals.  Some 
animals  remained  well  after  leaving  a  cannula  in  the  jugular  vein 
for  several  hours.  Death  was  sure  to  follow  if  after  the  insufflation 
of  air  the  vein  was  ligated.  Animals  who  had  previously  lost  large 
quantities  of  blood  readily  succumbed  to  intravenous  admission 
of  air. 


INTRA-ARTERIAL   INSUFFLATION   OF  AIR.  233 

Laborde  and  Muron,  who  studied  the  effects  of  intravenous  and 
intraarterial  insufflation  of  air,  placed  great  stress  on  the  manner  in 
which  the  injections  were  made,  in  determining  the  gravity  of  the 
symptoms.  They  observed  that  in  case  the  insufflations  into  veins 
were  made  slowly  and  repeated  at  intervals,  large  quantities  wore 
tolerated  without  exciting  serious  symptoms.  If,  on  the  other 
hand,  they  were  made  suddenly  and  with  force,  and  the  quantity  of 
air  was  considerable,  death  resulted  almost  instantaneously  from 
arrest  of  the  heart's  action  in  the  diastole,  an  occurrence  which  was 
attributed  by  these  authors  to  over-distention  of  the  right  side  of  the 
heart. 

In  repetition,  it  may  be  stated,  that  the  immediate  cause  of 
death  after  intravenous  injection  of  air  has  been  referred  by  differ- 
ent experimenters  to: 

1.  Mechanical  over-distention  of  the  right  ventricle  of  the 
heart  and  paralysis  of  this  organ  during  the  diastole. 

2.  Acute  cerebral  ischaemia. 

3.  Asphyxia  from  obstruction  to  the  pulmonary  circulation 
consequent  upon  embolism  of  the  pulmonary  artery. 

IX.    Intra-Arterial    Insufflation   of  Air. 

As  the  accidental  admission  of  air  never  takes  place  in  wounds 
of  the  arteries  on  account  of  the  high  degree  of  intravascular 
pressure  and  the  absence  of  any  aspiratory  force,  it  is  not  surprising 
that  the  effect  of  the  artificial  introduction  of  air  into  these  vessels 
has  been  made  less  frequently  an  object  of  experimental  research 
than  intravenous  insufflation  of  air.  The  subject  is  devoid  of  any 
practical  value,  and  the  interest  attached  to  it  is  of  a  purely 
scientific  nature.  As  we  have  already  seen,  Bichat.  entertained  the 
idea  that  atmospheric  air  acts  as  a  direct  irritant  to  the  substance  of 
the  brain  when  brought  in  contact  with  that  organ  through  the 
medium  of  the  cerebral  vessels,  and  death  from  insufflation  of  air, 
whether  into  veins  or  arteries,  was  invariably  attributed  by  him  to 
eerelual  anosmia. 

I'anum,'  in  his  researches  on  embolism,  made  arterial  insufflation 
of  air  also  a  subject  of  experimentation.      A  rapidly  fatal  termina- 

Op.  oit. 


234  EXPERIMENTAL  SURGERY. 

tion  followed  the  injection  of  4  cubic  centimeters  of  air  into  the  lower 
portion  of  the  carotid  artery  of  a  medium -sized  dog.  The  infunda- 
tion  was  followed  immediately  by  severe  general  convulsions,  alter- 
nating with  violent  attacks  of  rage.  The  animal  foamed  at  the 
mouth,  and  had  involuntary  discharges  from  the  bladder  and  bowels, 
the  eyes  became  prominent,  and  the  pupils,  at  first  dilated,  con- 
tracted, and  remained  so  permanently.  The  animal  soon  became 
quiet  and  motionless.  Respiration  and  heart's  action  slow.  The 
right  anterior  and  both  posterior  extremities  were  extended  and  rigid, 
while  the  left  front  leg  remained  relaxed.  Conjunctiva  insensible, 
while  touching  the  cornea  produced  contractions  of  the  eyelids.  For 
two  hours  the  animal  remained  in  a  condition  resembling  anaesthesia, 
without  changing  its  position,  with  slow  pulse  and  respiration,  when 
life  ceased  without  a  tremor  or  convulsion. 

The  postmortem  examination  showed  numerous  punctiform 
ecchymoses  in  the  gastro-intestinal  mucous  membrane,  the  liver, 
diaphragm,  and  abdominal  muscles.  The  superficial  vessels  of  the 
brain,  more  particularly  the  veins,  were  extremely  hypersemic;  the 
jugular  veins  were  distended  to  their  utmost  with  blood.  The  small 
arteries  contained  many  air-bubbles,  so  that  the  smallest  vessels  pre- 
sented varicose  dilatations  which  resembled  a  string  of  pearls.  The 
large  vessels  at  the  base  of  the  brain  also  contained  air,  and  numer- 
ous red  spots  were  disseminated  throughout  the  white  substance  of 
the  brain. 

Laborde  and  Muron  '  witnessed  after  the  introduction  of  20-60 
cubic  centimeters  of  air  into  the  carotid  artery  of  dogs,  when  injected 
in  a  peripheral  direction,  that  death  was  produced  rapidly  and  was 
always  preceded  by  tetanic  convulsions  and  labored  respiration; 
while  if  the  quantity  of  air  injected  was  smaller,  and  especially  if 
the  air  was  thrown  in  in  divided  doses,  the  animal  often  survived  the 
experiment  for  twenty-four  hours.  In  the  latter  class  of  cases  the 
operation  was  followed  by  tetanus,  vomiting,  paralysis,  and  coma. 
The  autopsy  revealed  softening  of  the  brain,  and  capillary  haemor- 
rhages, especially  in  the  middle  portion  of  the  brain,  the  medulla 
oblongata,  and  in  the  posterior  lobes  of  the  cerebrum.  The  intra- 
arterial insufflations  of  air  in  all  these  experiments  were  immediately 
followed  by  grave  cerebral  symptoms  which  can  only  be  interpreted 

1  Virchow  u.  Hirsch's  Jahresbericht,  vol.  i.  1873,  p.  268. 


1NTRA-ARTERIAL   INSUFFLATION   OF  AIR.  235 

by  the  constant  post-mortem  appearances,  air-embolism  of  the  cere- 
bral vessels,  and  extreme  ischemia  of  the  brain. 

The  presence  of  air  in  the  arteries,  on  the  left  side  of  the  heart, 
is  followed  by  an  entirely  different  series  of  phenomena  than  in  the 
veins  on  the  right  side  of  the  heart.  The  acnte  ischaemia  of  the  brain 
thus  induced  is  invariably  manifested  by  tetanic  rigidity  of  the  vol- 
untary muscles  and  almost  complete  suspension  of  the  respiratory 
movements  of  the  chest.  The  contractions  of  the  left  ventricle  are 
so  powerful  as  to  overcome  these  additional  impediments  and  to 
completely  evacuate  the  chamber.  The  air  is  expelled  as  soon  as  it 
enters  and  is  distributed  throughout  the  whole  arterial  system.  It 
may  be  readily  conceived  that  the  air  when  it  has  reached  the  aorta 
will  rise  into  the  carotid  arteries  and  thence  into  the  cerebral  vessels, 
distending  them  to  their  utmost  capacity.  In  such  instances  death 
results  from  sudden  cerebral  anaemia  before  the  air  can  gain  entrance 
into  the  venous  system  through  the  capillaries. 

That  the  presence  of  air  is  detrimental  to  the  nervous  system 
has  been  established  by  experiments  On  animals.  Bohnius  attributed 
to  the  air  when  introduced  into  the  vascular  system  poisonous  prop- 
erties, and  this  opinion  is  entertained  by  Neudorfer  even  at  the 
present  time.  Copeland  believed  that  the  oxygen  of  the  adventitious 
air  combines  with  the  carbonic  oxide  in  the  venous  blood,  producing 
carbonic  acid.  These  and  similar  theories  do  not  explain  the  phe- 
nomena observed  after  insufflation  of  air.  The  symptoms  during  life, 
and  post-mortem  appearances  point  directly  towards  physical  obstruc- 
tion in  the  blood-vessels  by  air-emboli,  which  suspends  the  function 
of  one  of  the  vital  organs,  and  consequently  must  be  regarded  as 
the  immediate  or  direct  cause  of  death. 

Insufflation  of  air  into  the  carotid  artery  towards  the  brain  is 
almost  immmediately  fatal.  If  a  moderate  quantity  of  air  is  forced 
through  the  arterial  system  into  any  other  organ  except  the  brain, 
it  does  no  particular  harm,  except  by  forming  a  temporary  obstruction 
in  the  circulation,  and  is  in  a  short  time  removed  by  absorption. 
This  fact  may  have  induced  Flint  to  make  the  following  remarks 
concerning  this  subject: '  "Air  injected  into  the  arteries  produces  no 
such  serious  effects  as  air  in  the  veins.  It  is  arrested  in  the  capil- 
laries of  certain  parts,  and  in  the  course  of  time  is  absorbed  without 
having  produced  any  injury." 
1  Op.  cit.,  p.  324. 


236  EXPERIMENTAL   SURGERY. 

The  danger  arising  from  the  introduction  of  air  into  the  arteries 
or  left  side  of  the  heart  comes  from  obstruction  to  the  circulation 
through  the  cerebral  vessels  by  air-emboli,  and  the  cessation  of  the 
functions  of  the  brain  consequent  upon  an  almost  complete  ischsemia 
of  this  organ.  The  mechanical  distention  of  the  left  side  of  the 
heart  by  the  accumulated  air  is  overbalanced  by  the  powerful  con- 
tractions of  the  left  ventricle,  which  are  sufficient  to  empty  the 
chamber  almost  completely,  and  to  force  the  air  into  the  ultimate 
distributions  of  the  arteries,  causing  acute  anaemia  in  distant  organs, 
but  more  particularly  in  the  brain.  In  these  instances  the  air  is 
forced  directly  into  the  cerebral  vessels  either  by  the  injecting  force, 
or  the  powerful  contractions  of  the  left  ventricle;  and  if  death  takes 
place,  it  follows  as  the  direct  result  of  acute  cerebral  ischsemia. 

X.    Clinical  Study  of  Air-Embolism. 

All  physiologists  agree  that  regular  and  deep  inspirations  pro- 
duce a  powerful  aspiration  in  the  large  veins  near  the  base  of  the 
heart,  more  particularly  in  the  jugular  and  subclavian  veins.  This 
fact  is  so  well  known  that  the  base  of  the  neck  and  the  clavicular 
regions  are  frequently  referred  to  as  the  "  danger  zone."  During 
the  inspiratory  act  the  chest  expands,  and  the  flow  of  venous  blood 
is  accelerated  towards  the  cardiac  or  proximal  side.  A  diversity  of 
opinion  still  exists  among  authors  in  regard  to  the  distance  to  which 
this  force  directly  affects  the  venous  circulation.  Experiment  and 
clinical  observation  have  shown  that  the  danger  of  entrance  of  air 
into  wounded  veins  is  increased  as  the  wound  approaches  the  heart. 

Berard  studied  the  anatomical  conditions  of  the  vessels  where 
entrance  of  air  has  most  frequently  taken  place,  and  he  came  to  the 
conclusion  that  this  accident  can  happen  only  when  the  wounded 
vessel  is  empty,  and  its  walls  are  prevented  from  collapsing,  and  the 
wound  remains  patulous.  He  found  these  conditions  normally  pres- 
ent in  the  sinuses  of  the  dura  mater,  the  hepatic  veins,  the  superior 
vena  cava,  the  internal  jugular,  the  subclavian,  and  axillary  veins, 
because  the  walls  of  all  these  vessels  are  firmly  fixed  to  the  adjacent 
tissues,  which  prevents  their  collapse  on  being  wounded. 

It  has  been  further  shown  that  the  admission  of  air  is  favored 
by  pathological  conditions  which  affect  the  veins  in  a  similar  manner, 
as  the  existence  of  induration  of  their  walls,  the  result  of  chronic 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  23  i 

inflammation,  or  infiltration  by  neoplasms.  Experience  has  corrobo- 
rated these  views,  inasmuch  as  it  has  been  shown  that  this  accident 
has  occurred  most  frequently  in  operations  in  the  vicinity  of  veins 
which,  from  their  anatomical  location,  are  prevented  from  collapsing 
by  firm  and  unyielding  layers  of  fascia,  and  vessels  which  are, 
or  have  become,  adherent  to  unyielding  tissues.  Again,  it  is  always, 
with  reason,  feared  in  removing  tumors  which  have  become  adherent 
to  large  veins,  as  the  morbid  process  has  frequently  so  impaired  the 
normal  resiliency  of  the  vessel  as  to  keep  its  lumen  patent  in  the 
event  of  its  being  wounded  during  the  dissection. 

In  thirty -three  cases  of  intravenous  aspiration  of  air  collected 
by  Couty,1  air  entered  the  external  jugular  nine  times,  the  axillary 
eight  times,  the  internal  jugular  five  times,  the  subscapulars  three 
times,  the  facial  twice,  the  anterior  jugular  twice,  the  occipital  twice, 
and  twice  one  of  the  anterior  thoracic  veins  in  close  proximity  to  the 
clavicle.  In  1864  Greene  collected  sixty-seven  cases  where  air  had 
entered  a  vein  during  an  operation.  The  greater  number  of  these 
cases  occurred  during  extirpation  of  tumors  in  the  region  of  the  neck, 
chest,  and  axilla.  Twice  the  accident  took  place  in  disarticulating 
the  humerus  at  the  shoulder  joint  (Cooper,  Delpech) ;  once  on  extir- 
pating the  scapula  and  clavicle  (Mussey);  twice  on  tying  the  sub- 
clavian artery  (Rigaud,  Clemot);  three  times  on  bleeding  from  the 
external  jugular  vein;  three  times  on  bleeding  from  the  median 
vein;  and  once  on  passing  a  seton-needle  through  the  tissues  in  the 
regions  of  the  neck.  Among  the  wounded  veins  the  external  jugular 
is  mentioned  thirteen  times,  the  internal  jugular  ten  times,  the  sub- 
clavian and  axillary  each  once.  In  the  remaining  cases  the  vein  is 
not  specified,  or  the  injury  involved  a  branch  in  close  proximity  to 
the  specified  vessels.2 

All  causes  which  interfere  with  the  free  return  of  venous  blood 
prevent  the  admission  of  air;  while,  on  the  other  hand,  all  influences 
which  promote  the  venous  circulation,  such  as  an  unimpaired  vis  a 
tergo,  regular  deep  inspiration,  and  the  force  of  gravitation  predis- 
pose to  this  accident.  Soon  after  I >eauchene  made  known  his  case, 
the  Royal  Academy  of  Medicine  of  Paris  appointed  a  commission  to 
investigate  the  subject.  In  the  report  it  is  stated  that  the  results  of 
the  experiments,  which  were  made  principally  on  dogs,  had  proven 

1  Op.  cit. 

2  American  Journal  of  the  Medical  Sciences,  18C1.  p.  ::h. 


238  EXPERIMENTAL  SURGERY. 

that  the  conditions  necessary  to  determine  the  entrance  of  air  con- 
sisted in  making  the  wound  in  the  vein  anywhere  within  the  area  of 
the  venous  pulse,  or,  at  any  rate,  only  a  short  distance  from  it.  If 
the  wound  was  located  at  a  greater  distance  and  beyond  the  influence 
of  the  venous  pulsations,  no  air  would  enter,  although  the  wound  was 
kept  open. 

The  experiments  were  also  to  determine  the  extent  of  the  venous 
pulse,  and  the  conclusions  arrived  at  were  that  the  brachial  and 
axillary  veins  were  beyond  the  venous  wave,  while  the  subclavian 
and  lower  third  of  the  jugular  veins  were  the  seat  of  pulsations; 
consequently  wounds  of  the  veins  in  these  localities  were  liable  to 
admit  air.  The  sound  produced  by  the  entrance  of  air  is  described 
as  resembling  the  lapping  of  a  dog  or  cat,  and  it  always  occurred 
during,  and  synchronous  with,  inspiration;  but  sometimes,  when  it 
was  heard  more  frequently,  it  accompanied  the  diastole  of  the  right 
ventricle.  After  the  air  had  entered  the  vein,  the  sound  which  could 
be  heard  on  auscultation  over  the  heart  was  described  as  a  "bruit  de 
soufflet,"  synchronous  with  the  action  of  the  heart.  In  regard  to  the 
effect  of  the  aspirated  air  it  was  decided  that,  in  order  to  produce  a 
fatal  result,  it  was  not  only  necessary  that  the  amount  of  air  intro- 
duced should  be  considerable,  but  that  it  should  be  thrown  into  the 
vein  with  some  degree  of  force. 

Hertwig  called  special  attention  to  the  fact  that  aspiration  of 
air  is  not  as  frequent  an  accident  as  is  generally  supposed,  and  that 
for  its  occurrence  the  peripheral  flow  of  blood  to  the  wound  must  be 
obstructed,  that  the  edges  of  the  vein  wound  must  be  drawn  apart, 
and  finally,  that  the  introduction  of  a  cannula  into  the  vein  is  neces- 
sary to  admit  a  sufficient  amount  of  air  to  produce  serious  results. 

The  first  case  of  admission  of  air  into  a  vein  that  was  recognized 
and  verified  by  a  post-mortem  examination,  occurred  in  the  practice 
of  Beauchene,  and  is  described  by  F.  Magendie.1  As  the  case  is  of 
great  historical  and  scientific  interest,  I  will  relate  it  as  described  by 
Magendie. 

A  locksmith,  twenty-three  years  of  age,  had  for  five  years  a  large  tumor 
on  the  right  shoulder  and  clavicle.  His  acute  sufferings  induced  him  to  enter 
the  hospital  to  have  it  removed.  It  was  necessary  in  the  operation  to  remove 
the  middle  portion  of  the  clavicle.     Thus   far   the  success  was  complete;  but 

1  Physiological  Researches  on  Life  and  Death,  by  X.  Bichat,  with  notes  by 
F.  Magendie.     Translated.     Boston,  1827,  p.  188. 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  239 

little  blood  was  lost,  the  pulse  was  good,  and  the  breathing  easy,  when  the 
patient  suddenly  cried  out:  "  My  blood  is  leaving  my  body!  I  am  dead!"  At 
the  same  moment  he  became  stiff,  lost  his  consciousness,  and  was  covered  with 
a  cold  sweat.  A  singular  and  rather  loud  noise  was  heard  in  the  interior  of 
his  chest.  The  surgeon  thought  that  he  had  opened  the  pleura  by  removing  a 
portion  of  the  clavicula.  and  thus  given  access  to  the  air  and  to  the  blood  to 
the  right  side  of  the  thorax.  The  fingers  of  an  assistant  were  immediately 
thrust  into  the  bottom  of  the  wound  with  a  view  of  stopping  the  supposed 
opening  in  the  pleura,  and  the  surgeon  endeavored  to  introduce  into  the  thorax 
the  extremity  of  a  sound  of  gum- elastic.  When  he  thought  that  he  had 
succeeded  he  drew  with  his  mouth  the  air  which  he  supposed  to  be  effused  in  the 
pleura.  He  wished  then  to  proceed  to  the  dressing,  and,  in  order  to  do  this, 
he  substituted  for  the  fingers  of  the  pupil,  which  were  at  the  bottom  of  the 
wound,  a  sponge  covered  with  wax;  but  the  moment  the  sponge  took  the  place 
of  the  fingers,  the  same  noise  that  was  at  first  heard,  and  which  had  ceased 
in  an  instant,  was  renewed  with  more  force  than  before.  The  syncope  and 
cold  sweat  still  continued.  Water  thrown  into  the  face  made  him  give  some 
signs  of  life,  but  he  died  a  quarter  of  an  hour  after  the  appearance  of  the 
accident  I  have  first  described,  and  forty-five  minutes  after  the  commence- 
ment of  the  operation.  The  body  was  examined  the  next  morning.  They 
expected  to  find  the  right  pleura  open,  much  blood  and  air  effused  into  its 
cavity,  and  the  lungs  on  that  side  collapsed.  Nothing  of  the  kind  was  found. 
The  pleura  was  whole  and  there  was  no  effusion  in  it.  The  lungs  were  as 
usual.'  but  an  opening  of  half  an  inch  in  extent  was  discovered  in  the  external 
jugular  vein,  at  the  place  where  this  vein  opens  into  the  subclavian.  The 
cavities  of  the  heart  were  large,  but  contained  no  blood.  Bubbles  of  air  were 
observed  in  the  vessels  of  the  brain;  the  other  vessels  were  not  examined. 

In  order  to  study  some  of  the  conditions  under  which  air  has 
been  aspirated  into  veins,  and  for  the  purpose  of  ascertaining  the 
effects  of  such  accidents  in  man,  I  will  introduce  a  number  of  well- 
aiithenticated  cases  which  will  represent  a  great  diversity  in  the 
point  of  entrance,  and  will  also  aid  in  the  establishment  of  the  fact 
that  this  accident  can  occur  outside  of  the  regions  of  venous  pulse, 
always  occurs  during  inspiration,  and  is  never  produced  by  the 
aspiratory  function  of  the  heart. 

External  Jugular.  Barlow's  case.1  The  patient  was  a  female  Buffering 
from  a  tumor  seated  on  the  side  of  the  neck,  which  had  been  increasing  in  size 
for  several  years;  its  base  was  extensive,  and  occupied  the  whole  of  the  lateral 
and  posterior  parts,  extending  from  the  ear  to  near  the  sternum,  and  sidewise 
from  the  thyroid  gland  to  the  sterno-mastoid  muscle,  under  which  a  pari  of 
the  tumor  was  situated.  The  patienl  was  seated  in  a  reclined  chair,  supported 
sietants.      Two  superficial  elliptical    incisions,  ten  inches  in  length,  were 

1  Medico-Chirurg.  Trans.,  vol.  xvi.  \>.  29. 


240  EXPERIMENTAL  SURGERY. 

made  downwards  from  a  little  below  the  ear,  "  when  on  proceeding  to  dissect 
the  skin  aside  to  get  at  the  basis  of  the  tumor,  a  sudden  and  unexpected 
hissing  and  gurgling  noise  rushed  obviously  from  a  large  divided  empty  vein, 
and  the  patient  expired  instantly,  without  either  sigh,  groan,  or  struggle,  and 
every  effort  to  restore  animation  became  fruitless."  The  divided  vein  appeared 
larger  than  the  normal  external  jugular,  but  the  reporter  believes  that  it  was 
this  vessel  or  an  anomalous  vessel  greatly  enlarged.  As  the  incisions  must 
have  traversed  the  external  jugular,  according  to  his  own  description,  it  was 
undoubtedly  this  vessel  which  was  injured.  It  is  distinctly  stated  that  the 
vessel  was  flabby  and  empty,  and  that  the  instant  the  atmospheric  air  gained 
access  and  filled  the  vacuum,  the  hissing  noise  ceased,  the  patient  expired,  and 
the  mouth  of  the  vessel  collapsed. 

Remarks. — In  this  case  the  admission  of  air  was  favored  by  the 
dilatation  of  the  vein,  and  the  semi-erect  position  of  the  patient. 
The  latter  factor  produced  the  emptiness  of  the  vein.  The  instan- 
taneous death  without  any  symptoms  preceding  it  can  only  be 
explained  by  the  fact  that  the  air  entered  the  right  ventricle  with 
force  and  in  large  quantity,  and  arrested  the  heart's  action  by  over- 
distention. 

Internal  Jugular.  Ulrice's  case.1  The  operation  was  performed  for  the 
removal  of  a  tumor  involving  the  left  side  of  the  neck.  It  was  found  that  the 
tumor  was  attached  to  the  deep  vessels  of  the  neck,  and  in  severing  its  connec- 
tion, the  internal  jugular  vein  was  opened.  No  haemorrhage  followed,  the  vessel 
remained  open  like  an  artery,  and  air  entered  immediately.  The  patient 
fainted;  twitching  of  the  muscles  of  the  face,  opisthotonos,  a  few  slow  respi- 
rations followed,  and  the  patient  was  dead.  The  vein  was  found  obliterated 
above  the  incision,  and  thickened,  and  more  resistant  than  normal  where  the 
wound  was  inflicted.  The  reporter  attributed  the  ingress  of  air  to  aspiration 
of  the  heart,  and  death  to  paralysis  of  this  organ. 

Remarks. — The  pathological  changes  in  the  vein  above  the 
wound,  interrupting  entirely  the  column  of  blood  from  above,  as 
well  as  the  thickening  of  the  incised  vein  walls,  were  potent  factors 
which  determined  the  entrance  of  air.  As  this  operation  was  per- 
formed before  anaesthetics  were  used,  we  may  be  almost  certain  that 
the  patient  was  in  a  sitting  or  half-reclining  position  during  the 
operation,  thus  favoring  greatly  venous  return  and  ingress  of  air. 
The  entrance  of  air  in  this  instance  is  brought  by  the  author  in  con- 
nection with  the  suction  power  of  the  heart,  in  accordance  with  the 
prevalent  doctrine  of  the  French  Commission. 

1  Rust's  Chirurgie,  Berlin,  1836,  vol.  xvii.  p.  565. 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  24] 

« 
Internal  Juijular.  Dupuytren's  case.1  The  operation  consisted  in  the 
removal  of  a  tumor  of  a  ribro-cellular  character  of  considerable  size  from  the 
neck  of  a  female,  twenty-two  years  of  age.  No  serious  obstacles  presented 
themselves  until  the  last  deep  attachment  was  severed  with  the  knife,  when 
suddenly  a  prolonged  hissing  noise  (Soufflement  prolonge)  was  heard,  resembling 
the  sound  produced  by  the  entrance  of  air  into  a  vessel  from  which  it  had  been 
exhausted.  The  patient  immediately  proclaimed  "I  am  dying,"  and  instan- 
taneously dropped  down  on  the  floor,  a  lifeless  corpse.  As  no  other  cause  was 
found  which  could  in  any  way  account  for  the  sudden  death,  the  fatal  issue 
was  attributed  to  the  entrance  of  air  into  the  internal  jugular  vein.  The 
following  account  of  the  post-mortem  appearances  fully  warrants  this  supposi- 
tion: "The  right  auricle  was  distended  with  air  like  a  bladder,  which  rushed 
out  when  cut  open  without  any  admixture  of  blood.  Fluid  blood  was  found 
in  different  vessels.  Great  quantities  of  air  were  found  in  all  the  vessels. 
There  was  no  other  unnatural  appearance  in  any  other  part  of  the  body." 

Remakks. — The  editor  of  the  Medical  and  Chirurgical  Review 
explained  the  entrance  of  air  in  this  case  as  follows:  "It  proves 
that  the  heart  acts  as  a  sucking  as  well  as  forcing  pump,  otherwise 
air  could  never  have  passed  from  a  cut  vein  in  the  neck  down  into 
the  right  chambers  of  the  heart.  It  is  highly  probable  that,  in 
consequence  of  the  morbid  state  of  the  parts,  the  mouth  of  the  cut 
vein  had  remained  patulous,  and' thus  readily  admitted  the  air."  As 
no  mention  is  made  of  the  occurrence  of  haemorrhage,  the  vein  was 
probably  empty,  a  condition  which  might  have  been  owing  to  the 
position  of  the  patient  during  the  operation  or  the  pressure  of 
the  tumor.  It  is  also  reasonable  to  assume  that,  on  account  of  the 
intimate  connection  of  the  tumor  with  the  vessel,  the  former  so 
altering  the  structure  of  the  latter  as  to  prevent  closure  of  the 
wound,  all  of  these  causes  combined,  resulting  in  aspiration  of  air 
during  inspiration. 

Facial  Vein.  Mott's  case.2  The  operation  consisted  in  extirpation  of  the 
parotid  gland,  the  seat  of  a  scirrhous  tumor.  The  facial  vein  was  opened, 
where  it  passes  over  the  base  of  the  lower  jaw,  in  dissecting  the  integuments 
from  the  tumor  in  the  early  stage  of  the  operation,  before  a  single  artery  was 
tied.  At  the  instant  this  vessel  was  opened,  the  attention  of  all  present 
was  arrested  by  the  gurgling  noise  of  air  passing  into  some  small  opening. 
The  breathing  of  the  patient  at  once  became  difficult  and  laborious,  the  heart's 
action  violent  and  irregular,  his  features  were  distorted,  and  convulsions  of 
the  whole  body  soon  followed  to  so  great  an  extent  as  to  make  it  impossible 
to  keep  him  on  the  table.     He  lay  upon  the  floor  in  this  condition  for  nearly 


1  Medico-Chir.  Trans.,  vol.  xvi.  p.  301. 
II. idem,  p.  32. 


242  EXPERIMENTAL  SURGERY. 

half  an  hour,  as  all  supposed  in  articulo  mortis.  The  convulsions  ceased 
gradually,  his  mouth  was  distorted,  and  complete  hemiplegia  was  found  to 
have  taken  place;  after  an  hour  had  passed  he  could  speak,  but  the  use  of  his 
arm  and  leg  was  only  completely  recovered  after  the  lapse  of  a  day. 

Remarks. — Although  not  stated,  it  was  undoubtedly  true  that 
in  this  instance  the  facial  vein  was  enlarged,  and  its  walls  had  lost 
their  normal  resiliency,  thus  favoring  the  ingress  of  air.  This  case 
is  also  of  interest,  as  from  the  predominance  of  the  cerebral  symp- 
toms it  is  apparent  that  some  of  the  air  must  have  passed  through 
the  pulmonary  circulation  and  have  gained  access  into  the  cerebral 
vessels  from  the  left  ventricle,  giving  rise  to  symptoms  of  cerebral 
embolism,  which  disappeared  as  the  air  was  absorbed. 

Axillary  Vein.  Bransby  Cooper's  case.1  The  patient  was  a  female,  nine- 
teen years  of  age,  who  was  the  subject  of  a  malignant  tumor  of  the  right 
humerus  which  required  amputation  at  the  shoulder- joint.  The  operation 
was  done  by  making  a  double  flap,  the  subclavian  artery  in  the  meantime 
being  compressed  against  the  first  rib.  There  was  no  loss  of  blood.  The 
subclavian  artery  was  secured,  compression  being  kept  up,  as  there  were  small 
vessels  which  required  ligation.  As  the  operator  was  removing  an  enlarged 
gland  from  the  axilla,  he  heard  distinctly  a  peculiar  gurgling  noise,  like  air 
escaping  with  fluid  from  a  narrow-neifked  bottle.  At  the  same  moment  the 
patient  fell  into  a  state  of  collapse  which  threatened  immediate  death.  The 
face  was  deadly  pale;  the  pupils  fixed  and  insensible  to  light;  the  pulse  small 
and  fluttering,  at  intervals  regular;  respiration  hurried  and  feeble,  and  at 
irregular  intervals  attended  with  a  sigh.  The  patient  was  placed  in  the 
recumbent  position,  the  flaps  closed,  and  stimulants  applied;  but  an  hour 
elapsed  before  she  had  sufficiently  recovered  to  be  removed  from  the  operat- 
ing room.  Subsequently,  when  placed  in  bed,  she  maintained  a  constant 
motion  of  alternate  flexion  and  extension  of  the  right  leg,  which  continued  for 
several  days;  at  the  same  time  she  complained  of  pain,  extending  up  the  right 
side  of  the  neck  and  head.  The  next  day  the  pulse  varied  from  140-150  per 
minute,  which  remained  the  same  for  two  days.  She  gradually  rallied  and 
recovered  completely. 

Remarks. — In  this  case  the  axillary  vein  was  divided  at  a  point 
where  its  walls  are  firmly  fixed  and  its  lumen  kept  patent  by  dense 
connective  tissue  which  surrounds  the  vessel,  a  condition  which  pre- 
disposes to  aspiration  of  air.  Pulmonary  air-emboli  obstructed  the 
passage  of  blood  through  the  lungs,  a  circumstance  which  would 
serve  to  explain  the  rapid  respiration  and  the  accelerated  action  of 
the  heart  until  the  obstructing  cause  was  removed. 

1  Med.-Chir.  Trans.,  vol.  xxvii.  p.  41. 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  243 

Axillary  Vein.  Courvoisier's  case.1  The  operation  was  performed  for 
the  removal  of  a  recurring  cancer  of  the  breast,  and  included  the  extirpation 
of  infiltrated  and  ulcerated  axillary  glands.  As  the  dissection  reached  the 
upper  margin  of  the  mass  of  axillary  glands  a  lapping  (schluerfendes) 
sound  was  suddenly  heard;  at  the  same  time  the  patient,  a  robust  woman 
fifty-eight  years  of  age,  sank  into  a  condition  of  collapse.  The  central  portion 
of  the  vein  was  at  once  closed  by  digital  compression,  and  artificial  respira- 
tion, with  the  administration  of  stimulants,  was  successful  in  restoring  her  after 
the  lapse  of  half  an  hour.  Both  ends  of  the  vein  were  ligated,  and  the  central 
ligature  included  the  forceps,  which  were  allowed  to  remain.  The  patient 
recovered. 

Remarks. — In  this  instance  the  entrance  of  air  was  again 
determined  by  the  anatomical  location  of  the  vein  wound,  to  which 
may  have  been  added  cancerous  infiltration  of  the  para-vascular 
tissues,  which  rendered  the  vein  walls  still  more  unyielding.  The 
amount  of  air  admitted  must  have  been  small,  to  judge  from  the 
evanescent  nature  of  the  symptoms  which  followed. 

Anterior  Thoracic  Vein.  Amussat's  case.2  The  patient  was  a  woman, 
forty-seven  years  of  age,  suffering  from  a  scirrhous  affection  of  the  right 
mammary  gland  and  the  subjacent  and  surrounding  tissues.  The  breast  and 
adjacent  tissues  had  been  removed,  and  the  operator  was  dissecting  towards 
the  opposite  side,  when  suddenly,  on  making  an  incision  into  some  suspicious 
granulations  on  the  inner  side  of,  and  below  the  left  clavicle,  he  and  three 
other  surgeons  who  were  assisting  him  heard  a  sudden,  distinct,  interrupted 
sound,  as  of  air  passing  into  a  cavity  through  a  narrow  opening.  The  patient 
exclaimed,  "  I  am  dying,"  and  appeared  to  be  suffocating.  A  repetition  of 
the  same  sound  convinced  the  operator  that  air  had  entered  through  a 
wounded  vein,  and  he  placed  his  finger  on  the  spot  from  which  the  sound  pro- 
ceeded. The  patient's  condition  became  critical,  a  cold  sweat  covered  her 
face,  her  eyes  were  turned  upwards,  and  all  around  her  thought  her  dying. 
The  orifice  of  the  wounded  vein  could  be  distinctly  seen.  The  chest  was  com- 
pressed with  a  view  to  force  out  the  air  from  the  vein,  the  wounded  spot  being 
compressed  during  the  expansion  of  the  chest.  The  patient  soon  began  to 
show  signs  of  improvement,  when  the  operation  was  completed,  and  the  vein 
with  a  portion  of  the  tissue,  was  tied.     The  patient  recovered  completely. 

Remarks. — Although  the  particular  vein  wounded  in  this 
instance  is  not  specified,  it  was  undoubtedly  a  branch  of  the  sub- 
clavian vein,  the  wound  being  in  close  proximity  to  the  latter  vessel. 
This  case  furnishes  a  good  illustration  of  the  fact,  that  veins  of 
comparatively   small    calibre,  when  wounded    near  their  proximal 

1  Oorrespondenzblatt  fur  Schweizer  Aerzte,  1880,  p.  205.  • 

2  Gazette  des  Hopitaux.  Julj  6,  L887. 


244  EXPERIMENTAL  SURGERY. 

termination  into  a  larger  vessel,  may  serve  as  points  of  entrance  of 
air  under  the  same  circumstances  as  when  the  principal  trunk  is 
injured. 

Superficial  Cervical  Vein.  Trelat's  case.1  M.  Trelat  related,  at  a  meeting 
of  the  Societe  de  Chirurgie  of  Paris,  an  important  case  in  which  sudden  death 
occurred  in  a  patient  from  whom  he  was  proceeding  to  remove  a  submaxil- 
lary tumor.  The  patient  turned  ghastly  pale,  and  the  heart's  action  ceased 
suddenly.  Artificial  respiration  and  electrization  of  the  phrenic  nerve  induced 
some  respirations  and  a  slight  return  of  color  after  fifteen  minutes,  but  ineffect- 
ually. At  the  post-mortem  examination  a  small  vein  opening  into  the  external 
jugular  was  found  to  have  been  partially  divided;  in  the  jugular  was  a  long 
clot  interspersed  with  air-bubbles,  and  other  bubbles  of  air  were  found  in  one 
of  the  mediastinal  veins  and  the  posterior  cardiac  vein,  and  a  very  notable 
quantity  of  air  in  the  right  chambers  of  the  heart. 

Remarks. — Several  members  of  the  society  argued  that  death 
in  this  instance  was  due  to  the  anaesthetic,  and  not  to  the  entrance 
of  air  into  the  vein.  Roux  and  Giraldes  claimed  that  in  several  cases 
of  death  from  chloroform  they  had  found  gases  in  the  heart,  in  the 
vena  cava,  and  even  in  the  veins  of  the  pelvis,  but  M.  Depaul,  in 
reply,  properly  and  forcibly  pointed  out  that  the  air  in  this  case 
occupied  only  the  veins  going  to  the  heart,  and  the  wounded  vein. 

Femoral  Vein.  The  only  well-authenticated  case  of  aspiration  of  air  into 
the  femoral  vein  that  I  have  been  able  to  find  is  recorded  in  the  Medical  and 
Surgical  History  of  the  British  Army  in  Turkey  and  the  Crimea,  vol.  ii.  p.  277, 
and  refers  to  the  sudden  death  of  a  soldier  who  had  suffered  amputation  of  the 
thigh,  from  this  cause.  Three  and  one-half  days  after  the  operation  he  died 
suddenly  without  any  obvious  cause.  At  the  necropsy,  twelve  hours  after 
death,  it  was  ascertained  that  the  right  cavities  of  the  heart  were  distended 
with  a  mixture  of  blood  and  air,  and  the  same  condition  was  found  in  the  two 
iliac  veins  and  the  inferior  vena  cava. 

Remarks. — As  the  time  which  had  intervened  between  the  oper- 
ation and  the  fatal  accident  was  more  than  three  days,  it  is  necessary 
to  assume  that  the  venous  thrombus  had  been  removed  by  suppura- 
tion, thus  opening  the  vein  for  the  admission  of  air,  or  that  the 
supposed  air  found  in  the  heart  and  vessels  was  not  air  but  gas 
which  had  developed  in  the  wounded  parts,  and  had  gained  entrance 
into  the  venous  circulation.  This  latter  siipposition  is  strengthened 
by  the  statement  that  the  surfaces  of  the  flaps  were  separated  by 
gaseous  products,  and  that  the  femoral  vain  was  not  closed  but  lay 
open  on  the  surface  of  the  stump. 

1  British  Medical  Journal,  March  1G,  1872. 


CLINICAL  STUDY   OF  AIR-EMBOLISM.  245 

Internal  Saphenous  Vein.  Warren's  case.1  The  operation  was  done  for 
the  removal  of  a  tumor  from  the  inner  surface  of  the  thigh.  In  the  dissection 
the  internal  saphenous  vein  was  wounded;  the  event  was  promptly  announced 
by  an  audible  and  distinct  sucking  sound  produced  by  the  entering  air.  No 
alarming  symptoms  followed,  as  the  further  ingress  of  air  was  promptly  pre- 
vented by  closure  of  the  vein. 

Uterine  Veins.  That  the  entrance  of  air  into  the  uterine  veins 
might  be  a  cause  of  danger  after  parturition  was  suggested  by 
Legallois  in  1829.  Dr.  John  Rose  Cormack  read  a  paper  on  this 
subject  before  the  Westminster  Medical  Society  in  1850,  in  which  he 
gave  the  details  of  three  cases  that  had  occurred  in  his  neighborhood. 
Many  authorities  doubt  the  possibility  of  admission  of  air  into  the 
uterine  veins  after  labor.  Julius  M.  Kolb"  alludes  to  this  subject  as 
follows:  "I  have  not  seen  a  case  which  convinced  me  that  air  had 
passed  into  the  open  veins  of  a  recently  delivered  uterus,  and  I  can- 
not conceive  the  mechanical  possibility  of  such  an  occurence."  Bes- 
sems,  Lionet,  Lever,  Wintrich,  Berry,  and  Simpson  assert  that  they 
have  met  with  such  instances,  and  a  sufficient  number  of  well- 
authenticated  cases  have  been  placed  on  record  to  leave  no  further 
doubt  as  to  the  possibility  of  sudden  death  in  puerperal  women 
from  entrance  of  air  into  the  uterine  sinuses. 

In  a  recent  number  of  the  Wiener  Medicinische  Zeitschrift, 
Braun  gives  three  fatal  cases  from  the  introduction  of  air  into  the 
uterine  veins ;  in  two  of  the  three  the  uterine  douche  was  used,  in  one 
to  produce  abortion,  in  the  other  after  delivery  of  twins,  and  the 
patients  died  in  a  short  time,  one  indeed  within  twenty  minutes. 
Post-mortem  examination  showed  air  in  the  uterine  veins,  in  the 
ascending  vena  cava,  and  in  the  veins  of  the  heart.  The  third  case 
was  that  of  a  woman  who  had  been  delivered  lying  upon  her  left 
side,  and  was  then  turned  upon  her  back;  massage  was  made  over 
the  uterus,  she  gasped,  and  died  in  a  few  minutes.  Braun  suggests 
that  in  the  change  of  position  a  volume  of  air  entered  the  uterus, 
ami  the  manipulation,  instead  of  driving  it  out,  forced  it  into  the 
uterine  veins.  Bischoff  refers  to  two  cases  I  hat  came  under  liis 
observation.8     Dr.  Draper4  has  reported  two   cases  where    instant 

Gazette  Medicale,  No.  52. 

-Pathological  Anatomy  of   1  h<-   Female  Sexual  Organs,  L868,  Am.  Trans. 
CorreBpondenzblatt  far  Schweizer  Aerzte,  1880,  p.  206. 
1  Boston  Medical  and  Surgical  Journal,  January,  1883. 


246  EXPERIMENTAL   SURGERY. 

death  occurred  from  efforts  to  cause  criminal  abortion.  The  post- 
mortem examination  proved  in  each  case  the  presence  of  air  in  the 
veins. 

Mr.  George  May1  reports  three  cases  which  occurred  in  his 
vicinity.  The  patients  died  respectively,  immediately,  six  hours,  and 
eight  days  after  delivery,  and  in  all  of  them  post-mortem  examina- 
tions showed  the  presence  of  air  in  large  quantities  in  the  inferior 
vena  cava  and  the  right  side  of  the  heart.  An  interesting  account 
of  this  accident  is  given  by  Dr.  George  Cordwent,  and  relates  to  a 
case  that  came  under  his  observation." 

His  patient  was  twenty-eight  years  of  age.  During  the  delivery,  at  full 
term,  her  expulsive  pains  became  urgent,  and  at  her  request  she  was  permitted, 
in  the  absence  of  her  medical  attendant,  to  remain  standing;  after  a  few 
severe  pains  the  child  was  expelled,  and  after  falling  on  the  floor,  dragged 
with  it  the  whole  placenta.  Almost  immediately  afterward  a  kind  of  gurgling 
sound  was  heard  by  the  attendants,  but  whether  it  arose  from  rumbling  in  the 
bowels  they  could  not  say.  The  patient  remained  about  one  minute  standing 
as  before  and  holding  on  to  the  bed-post;  she  then  cried  out:  "  I  can't  see! 
I  feel  faint!  lay  me  on  the  bed,"  and  expired  almost  instantly.  At  the 
necropsy,  twenty-four  hours  after  death,  it  was  shown  that  the  uterus  exter- 
nally presented  the  normal  appearances  of  a  recently  delivered  organ,  except 
that  a  portion  of  the  wall  of  its  fundus  to  about  the  extent  of  a  five-shilling 
piece  was  slightly  more  puffy  than  the  other  portions,  and,  on  cutting  into  it, 
air-bubbles  escaped.  There  had  been  no  laceration  of  the  placental  surface; 
the  uterine  cavity  contained  only  one  small  clot;  its  lining  membrane  was 
healthy.  The  coronary  vein  of  the  stomach  was  distended;  the  right  side  of 
the  heart  was  slightly  gorged,  and  when  the  auricle  was  punctured,  air-bubbles 
escaped  with  the  blood  which  it  contained. 

Davidson"'  reports  the  case  of  a  Hindoo  woman  who  was 
admitted  into  the  Kaira  Gaol  Hospital  and  safely  delivered  of  a 
female  child.  The  labor  was  in  every  respect  normal.  The  placenta 
came  away  at  the  usual  time,  and  there  was  no  postpartum  haemor- 
rhage. About  three-quarters  of  an  hour  afterward  the  woman  died 
without  any  apparent  cause.  There  had  been  no  haemorrhage  or 
convulsions.  The  patient  had  been  taking  some  nourishment  when 
she  suddenly  fell  back  and  expired.  At  the  post-mortem  examina- 
tion two  hours  after  death  the  uterus  was  found  empty,  with  large 
and  somewhat  distended  veins;  the  right  side  of  the  heart  contained 

1  British  Medical  Journal,  June  6,  1857. 

2  St.  George's  Hospital  Reports,  vol.  vi. 
:)  The  Lancet,  vol.  i.  1883,  p.  999. 


CLINICAL  STUDY   OF  AIR-EMBOLISM.  '247 

a  quantity  of  air  mixed  and  churned  up  with  blood,  which  escaped 
in  bubbles;  the  lungs  were  congested;  all  the  other  organs  were 
normal. 

A  most  interesting  and  convincing  case  is  related  by  Olshausen. 
It  is  most  convincing  on  account  of  the  painstaking  and  accurate 
post-mortem  examination  which  was  made  to  determine  the  cause 
of  death.1 

A  robust  secundipara,  aged  twenty-nine,  was  delivered  at  full  term.  The 
uterus  was  unusually  distended;  no  albumen  in  urine.  The  labor  was  lingering 
and  the  uterine  douche  was  used.  The  water  was  of  30°  R.  and  was  forced 
into  the  vagina  gently  by  a  pump.  A  third  injection  was  made  by  a  midwife. 
After  eight  minutes'  use  the  patient  began  to  complain  of  oppression.  The 
tube  was  withdrawn.  The  patient  rose  in  bed,  immediately  fell  back  senseless, 
and  died  in  less  than  a  minute  under  convulsive  respiratory  movements  and 
distortion  of  the  face.  Eight  minutes  later  bleeding  by  the  median  vein  was 
tried,  but  only  a  few  drops  flowed.  On  touching  the  body  distinct  and  wide- 
spread crepitation  was  felt. 

Autopsy  eight  hours  after  death. — A  large  quantity  of  dark  fluid  blood 
escaped  from  the  sinuses  of  the  dura  mater.  The  cerebral  membranes  very 
hyperaemic;  brain  normal,  lungs  somewhat  congested,  heart  lying  transversely, 
apex  in  fourth  intercostal  space.  Left  ventricle  in  firm  contraction,  right 
quite  soft,  something  like  an  intestine  with  thick  walls;  the  coronary  vessels 
contained  a  quantity  of  air  bubbles.  Left  heart  contained  only  a  small  quan- 
tity of  blood;  the  right  held  little,  but  it  was  frothy.  The  distended  uterus 
crepitated  everywhere  on  pressure  under  the  hand.  A  number  of  subperitoneal 
vessels  of  medium  size  were  plainly  seen  to  be  filled  with  air.  The  right 
broad  ligament  was  strongly  distended  with  air  bubbles,  and  this  emphysema 
of  cellular  tissue  extended  from  the  broad  ligament,  through  the  retro-peri- 
toneal space  to  the  inner  side  of  the  right  kidney,  and  even  below  the  liver  to 
the  inferior  vena  cava.  The  inferior  vena,  cava  was  enormously  distended — it 
was  at  least  an  inch  in  diameter — containing  mostly  air.  The  uterus  was 
divided  in  the  median  line;  a  placenta  was  attached  to  the  anterior  wall;  a 
small  flap  was  detached  from  the  uterus,  a  second  placenta  was  attached 
behind  and  to  the  right;  a  larger  portion  of  this  had  been  separated,  so  that 
there  was  a  sort  of  pouch  between  it  and  the  anterior  wall.  The  two  ova  were 
uninjured.  The  air  had  gained  access  into  the  veins  at  the  placental  site.  It 
was  concluded  that  the  tube  had  been  passed  into  the  uterine  cavity  and  that 
air  had  been  thrown  in  with  the,  water  by  the  pump. 

It  would  be  difficult  to  conceive  in  what  manner  air  could  be 
drawn  into  the  uterine  veins  by  the  aspiratory  movoments  of  the 
chest  or  heart,  as  is  the  case  in  the  veins  about  the  apex  of  the 
chest.     Another  explanation  must  be  sought  for,  and  this  will  be 

1  Monats.  f.  Geburtskunde,  Jan.   1865.      Am.  Journ.  Med.  Sci.  July,  1865. 


248  EXPERIMENTAL  SURGERY. 

found  in  the  change  of  structure,  and  the  relations  of  the  uterine 
veins.  The  veins  during  pregnancy  keep  pace  with  the  enormous 
physiological  hyperplasia  of  the  uterine  tissues,  and  are  gradually 
converted  into  large  sinuses,  more  especially  the  vessels  at  the 
placental  site;  they  are  simply  excavations  or  channels  in  the  con- 
tractile muscular  walls  of  the  uterus,  their  size  being  subject  to  the 
state  of  the  uterine  walls,  whether  at  rest,  relaxation,  or  contraction. 
When  the  placenta  is  detached,  some  of  these  sinuses  are  laid  open, 
and  in  a  normal  condition  their  calibre  is  obliterated  by  the  contrac- 
tions of  the  uterus  and  the  formation  of  thrombi. 

If,  from  any  cause,  air  should  reach  the  uterine  cavity,  it  may 
be  aspirated  into  the  uterine  sinuses  by  relaxation  of  the  uterine 
contractions,  and,  having  gained  access  into  them,  it  is  readily  forced 
into  the  circulation  by  subsequent  contractions,  the  uterine  walls 
acting  the  part  of  a  suction  and  forcing-pump.  During  forcible 
uterine  contractions  the  veins  are  nearly  emptied  of  their  contents, 
and,  as  the  organ  relaxes,  the  walls  of  the  veins  are  distended  and  a 
vacuum  is  formed,  which  is  filled  with  blood  or  air.  Should  the 
relaxation  be  slow,  the  empty  spaces  are  readily  filled  with  blood  or 
serum  in  the  absence  of  air,  but  if  the  uterus  relaxes  quickly  the 
suction  power  is  proportionately  greater;  and,  in  case  air  has  reached 
the  uterine  cavity,  it  is  aspirated  into  the  open  veins;  and,  by  reach- 
ing the  right  side  of  the  heart  through  the  vena  cava,  it  gives  rise 
to  the  same  train  of  symptoms  as  when  it  is  admitted  into  a  vein 
during  a  surgical  operation  in  the  regions  of  the  neck. 

Pulmonary  Vein.  Dumin's  case.1  This  is  the  only  case  on  record  where 
it  is  claimed  that  death  was  produced  by  the  entrance  of  air  from  a 
pulmonary  tubercular  cavity  through  the  pulmonary  v«in  into  the  left  side  of 
the  heart.  The  patient  was  a  young  man  suffering  from  pulmonary  tuber- 
culosis in  the  last  stage.  Physical  diagnosis  revealed  a  large  cavity  in  the 
apex  of  the  right  lung.  After  the  patient  had  been  in  the  hospital  for  three 
weeks  the  general  conditions  remained  about  the  same,  while  the  local 
destructive  process  had  been  progressing.  One  day,  after  eating  his  dinner, 
he  arose  from  his  bed,  fell  down,  and  expired  almost  instantly  without  uttering 
a  word  or  sound. 

At  the  post-mortem  examination,  twenty-four  hours  after  death,  it  was 
found  that  the  apex  of  the  lung  contained  a  cavity  of  considerable  size, 
besides  extensive  crude  infiltrations.  The  left  lung  contained  numerous 
nodules  and  three  small  cavities.      The  third  cavity  in  the  substance  and  near 

1  Berliner  Klin.  Wochenschrift,  January  30,  1882. 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  249 

the  base  of  the  lung  contained  a  small  amount  of  blood  intimately  mixed 
with  air-bubbles.  The  heart  was  slightly  dilated.  The  left  ventricle  was  filled 
with  blood  mixed  with  innumerable  small  air-bubbles.  The  right  cavity  also 
contained  air,  but  in  much  lesser  quantity.  All  the  larger  arteries  contained 
air  mixed  with  blood;  air-bubbles  were  also  found  in  the  vena?  cavae  and  the 
pulmonary  artery.  The  arteries  and  veins  in  the  brain  and  meninges  were 
found  distended  almost  exclusively  with  air.  No  signs  of  advanced  putrefac- 
tion could  be  found,  and  none  of  the  parenchymatous  organs  contained  gases. 
The  reporter  explained  the  sudden  death  by  the  entrance  of  air  from  the 
small  cavity  in  the  left  lung,  which  contained  spumous  blood,  the  air  having 
found  its  way  into  an  open  branch  of  the  pulmonary  vein,  and  from  thence 
into  the  left  side  of  the  heart.  The  air,  which  was  found  in  the  right  side  of 
the  heart  and  veins,  according  to  his  view,  had  passed  through  the  systemic 
capillaries.      As  the  direct  cause  of  death,  anaemia  of  the  brain  is  mentioned. 

Remarks. — It  seems  to  me  that  several  reasons  might  be  men- 
tioned which  would  throw  doubt  on  the  correctness  of  the  assertion 
that,  in  this  case,  the  immediate  cause  of  death  was  owing  to 
entrance  of  air  into  the  pulmonary  vein.  1.  The  time  which  had 
elapsed  from  the  commencement  of  the  attack  until  death  took  place 
was  not  sufficient  to  produce  such  an  extensive  distribution  of  air, 
unless  it  could  be  proved  that  the  heart's  action  continued  after 
respiration  had  ceased.  2.  The  existence  of  an  open  vessel  in  any 
of  the  cavities  was  not  proven  at  the  examination  after  death.  3. 
The  body  appears  to  have  been  affected  by  a  certain  amount  of 
putrefaction,  which  may  have  been  sufficient  in  degree,  to  give  rise 
to  the  evolution  of  gases,  and  the  putrefactive  changes  may  have 
been  limited  to,  or  were  at  least  farthest  advanced  in,  the  blood, 
which  would  explain  the  absence  of  gas  in  any  other  part  of  the 
body,  except  within  the  blood-vessels.  4.  Syncope  is  a  frequent 
cause  of  sudden  death  in  greatly  debilitated  patients  when  the  heart 
is  called  upon  to  perform  an  increased  amount  of  labor,  as  when  the 
patient  suddenly  assumes  the  erect  position. 

Superior  Longitudinal  Sinus.  Volkmann's  case.1  The  only  fatal  case  of 
admission  of  air  into  the  sinuses  of  the  dura  mater  is  reported  by  Genzmer. 
The  patient  was  a  female,  sixty-three  years  of  age,  who  was  affected  with  a 
perforating  sarcoma  of  the  dura  mater.  The  tumor  was  noticed  about  two 
years  before  the  operation,  and  was  Located  in  the  region  of  the  posterior 
extremity  of  the  Bagittal  suture,  and  for  a  long  time  gave  rise  to  no  incon- 
venience. For  the  last  sizmontheil  caused  intense  headache.  On  one  occasion. 
a  physician  believing  thai   it.  was  an  atheroma,  attempted  its  removal,  but  as 

1  Verhandlungen  d.  Deutschen  Gesellschafl  t.  Chiwirgie,  vol.  \i.  p.  32. 


250"  EXPERIMENTAL  SURGERY. 

the  first  incision  gave  rise  to  copious  haemorrhage,  he  desisted  from  any  further 
attempts,  and  the  wound  healed  kindly. 

When  the  patient  was  admitted  under  Volkmann's  care  into  the  Clinic  at 
Halle,  the  tumor  presented  a  lobulated  appearance,  being  composed  of  three 
parts,  each  about  the  size  of  a  plum,  and  was  located  over  the  posterior 
extremity  of  the  sagittal  suture.  On  touch,  the  tumor  was  soft  and  elastic,  and 
imparted  to  the  finger  distinct  pulsations.  Gradual  compression  reduced  its 
size  one-half;  when  the  pressure  was  discontinued  it  resumed  its  former 
dimensions.  On  auscultation,  a  blowing  sound  was  heard  synchronous  with 
the  radial  pulse.  By  pressing  the  end  of  the  index  finger  deeply  between  the 
lobes  of  the  tumor,  a  bony  defect  in  the  skull  was  readily  detected.  The  con- 
clusion was  reached,  that  the  tumor  had  sprung  from  the  dura  mater,  and  had 
perforated  the  skull  by  the  prolonged  pressure,  causing  interstitial  absorption 
of  the  cranial  vault.  During  the  patient's  stay  in  the  hospital  the  tumor 
increased  very  rapidly  in  size.  As  no  brain  symptoms  were  present,  it  was 
assumed  that  the  substance  of  the  brain  was  intact. 

In  view  of  the  speedy  fatal  issue,  which  of  necessity  would  take  place 
without  operative  interference,  Volkmann  decided  to  remove  the  tumor.  The 
operation  was  done  April  2,  1875.  Under  strict  antiseptic  precautions  the 
tumor  was  exposed  by  a  crucial  incision,  and  the  flaps  reflected  with  the  peri- 
osteum to  the  margins  of  the  opening  in  the  skull.  The  aperture  in  the  bone 
measured  5.5  by  4.5  cm.  in  diameter.  With  a  Luer's  cutting  forceps  the  open- 
ing was  enlarged  to  7  by  8  cm.  The  tumor,  when  exposed,  was  nearly  as  large 
as  a  fist,  and  firmly  adherent  to  the  dura  mater.  The  dura  mater  was  carefully 
divided  around  the  margins  of  the  tumor,  which  had  now  been  liberated  from 
all  its  attachments  except  the  falx  cerebri.  It  was  now  drawn  forward  through 
the  opening  in  the  skull,  and  the  falx  cerebri  divided  with  scissors  from  before 
backwards.  This  step  of  the  operation  was  attended  by  alarming  hemor- 
rhage. As  the  blood  was  being  sponged  away  to  expose  momentarily  the  field 
of  operation,  a  peculiar  and  characteristic  lapping  sound  was  heard,  which 
indicated  to  all  present  that  air  had  entered  the  longitudinal  sinus.  At  the 
same  time  the  assistant,  who  was  giving  the  chloroform,  remarked,  "  She  is 
dying."  The  wound  was  immediately  compressed  with  a  large  carbolized 
sponge.  The  patient  was  in  collapse,  her  breathing  was  interrupted  and 
stertorous. 

After  a  short  pause,  it  was  determined  to  complete  the  operation,  but  as 
soon  as  the  tumor  was  again  drawn  forward,  and  its  attachment  at  the  junction 
of  the  longitudinal  with  the  transverse  sinuses  was  divided,  air  again  entered, 
accompanied  by  the  same  characteristic  sound.  The  tumor  was  separated 
rapidly  from  its  remaining  attachments,  and  a  Lister  dressing  was  applied  in 
such  a  manner  as  to  make  at  the  same  time  a  requisite  amount  of  compression 
for  the  double  purpose  of  arresting  haemorrhage  and  preventing  further 
ingress  of  air.  At  this  time  the  patient  was  pulseless,  pupils  dilated,  extremi- 
ties cold  and  blue.  Auto-transfusion,  by  constricting  the  arms  and  legs  with 
elastic  bandages,  had  the  effect  of  momentarily  stimulating  the  heart,  but 
respiration  became  more  irregular  and  interrupted,  and  after  a  few  more  brief 
moments  the  patient  died. 


CLINICAL   STUDY   OF  AIR-EMBOLISM.  251 

At  the  post-mortem  examination,  which  was  held  on  the  following  day, 
the  right  side  of  the  heart  was  opened  under  water  and  air-bubbles  escaped, 
showing  conclusively  that  air  had  made  its  entrance  through  the  longitudinal 
sinus.  The  left  side  of  the  heart  contained  no  air.  Air  was  also  found  in  the 
pulmonary  artery  and  the  subpleural  vessels.  The  left  side  of  the  brain  had 
suffered  more  from  compression  by  the  tumor  than  the  right.  The  defect  in 
the  dura  mater  corresponded  to  the  opening  in  the  skull.  An  additional  source 
of  haemorrhage  was  detected  at  the  posterior  margin  of  the  defect  in  the 
cranium,  where  the  opening  of  a  vein  5  mm.  in  diameter,  in  the  substance  of 
the  bone,  could  be  seen.  Under  the  microscope  the  tumor  showed  small 
spindle-shaped  cells,  with  a  very  vascular  intercellular  substance. 

Remarks. — In  this  case  all  circumstances  favored  the  entrance 
of  air  into  the  wounded  sinus.  The  sudden  and  severe  loss  of  blood 
from  such  a  large  reservoir  as  the  longitudinal  sinus  rendered  the 
vessel  empty,  thus  creating  the  most  essential  element  in  the  causa- 
tion of  air  aspiration.  The  position  of  the  patient  during  the 
operation  undoubtedly  was  such  that  the  force  of  gravitation  assisted 
materially  in  the  formation  of  the  vacuum.  The  walls  of  the  sinus 
being  rigid  and  attached  to  the  surrounding  structures  prevented 
collapse  of  the  vessel,  and  held  the  wound  patulous.  That  death 
was  owing  to  the  introduction  of  air  is  sufficiently  proven  by  the 
symptoms  during  life  and  the  evidences  derived  from  the  post- 
mortem examination. 

Veins  of  Diploe.  Franck1  asserts  that  he  has  repeatedly  seen 
aspiration  of  air  into  the  veins  of  the  diploe  after  trephining.  He 
claims  that  the  air  reaches  the  heart  through  the  medium  of  the 
vertebral  veins,  which,  from  their  protected  position,  are  more  favor- 
ably located  for  this  purpose.  By  experiments  he  proved  that  liga- 
tion of  the  jugular  veins  does  not  prevent  the  aspiration  of  air 
through  the  veins  of  the  diploe,  while,  on  the  other  hand,  this  acci- 
dent cannot  happen  when  the  vertebral  veins  are  compressed. 

As  the  veins  of  the  diploe  in  some  instances  are  unusually 
large,  and  their  walls  firmly  attached  to  the  unyielding  bone  tissue, 
they  constitute  channels  which  cannot  contract  in  case  they  are 
injured;  consequently  we  should  a  priori  expect  that  aspiration  of 
aii  will  take  place  under  the  same  circumstances  as  in  the  case  of 
the  sinuses  of  the  dura  mater,  and  in  all  extensive  injuries  of  the 
cranial  bones  the  same  caution  should  be  exercised  to  guard  against 

1  Bui  la  transmission  de  Inspiration  thoracique  jusqu' aux canaux  veineux 
■    da  crane,  etc.     Gazette  Mi'-dioale,  No  25,  1881. 


252  EXPERIMENTAL   SURGERY. 

this  accident.  In  troublesome  haemorrhage  from  venous  sinuses  in 
bone,  the  bleeding  is  promptly  and  safely  arrested  by  implantation 
of  an  aseptic  sponge,  which  can  be  left  in  situ,  as  it  will  be  removed 
by  the  granulation  tissue  during  cicatrization.  In  such  instances 
the  sponge  is  peculiarly  well  adapted,  as  the  lumen  of  the  vessel  is 
surrounded  by  unyielding  bony  walls,  which  will  support  any  amount 
of  pressure  on  the  part  of  the  aseptic  tampon. 

XI.    Experiments  on  Tenons  Air- Embolism. 

The  injection  of  air  was  always  made  into  the  jugular  vein. 
The  neck  was  shaved,  and  the  surface  disinfected  with  a  five  per 
cent,  solution  of  carbolic  acid.  Ether  was  always  used  as  an  anaes- 
thetic, the  animal  being  kept  fully  under  its  influence  until  every- 
thing was  in  readiness  to  throw  in  the  air,  when  the  inhalation  was 
suspended,  and  the  animal  was  allowed  to  come  out  from  under  its 
influence,  for  the  purpose  of  studying  the  effects  of  the  air  on  the 
heart  and  respiration,  independently  of  the  effects  of  the  anaesthetic. 
The  vessel  was  freely  exposed,  usually  in  the  lower  part  of  the  neck, 
by  a  parallel  incision.  After  isolating  it  to  the  extent  of  from  two 
to  four  inches,  the  influence  of  the  respiratory  movements  of  the 
chest  on  the  venous  circulation  was  carefully  studied.  Then  a 
haemostatic  forceps  was  applied  to  the  distal  portion  of  the  vein. 
Below  the  point  of  compression  the  blood  was  forced  out  of  the 
vessel  between  two  fingers,  and  its  return  prevented  by  applying 
another  pair  of  forceps  to  the  proximal  end  of  the  exposed  vein. 
We  had  thus  a  bloodless  portion  of  vein  between  the  forceps,  pre- 
senting a  ribbon-like  band.  This  was  partially  divided  in  an  oblique 
direction  for  the  purpose  of  facilitating  the  introduction  of  a 
cannula. 

The  cannula  being  securely  fastened  in  the  vein  by  a  ligature, 
when  the  proximal  pair  of  forceps  were  removed,  and,  by  compress- 
ing the  bulb,  the  air  was  injected  with  force,  so  as  to  imitate  as 
nearly  as  possible  the  conditions  present  during  the  accidental  intro- 
duction of  air.  The  cannula  was  connected  with  a  rubber-bulb  of 
known  capacity,  by  means  of  a  rubber-tube.  After  the  completion 
of  the  experiment  (if  the  animal  survived)  the  vessel  was  divided 
completely,  and  both  ends  ligatured  with  catgut,  and  the  wound 
closed  with  a  continued  catgut  suture.  The  weight  of  the  animal  and 
amount  of  air  injected  were  estimated  accurately  in  most  instances. 


EXPERIMENTS   OX    VENOUS  AIR-EMBOLISM.  253 

Experiment  1.  Sheep,  weighing  one  hundred  and  twenty  pounds.  Left 
jugular  vein.  The  vessel  was  opened  in  its  lower  third,  but  no  air  entered. 
A  rubber-tube  was  introduced  for  a  distance  of  two  inches  with  a  view  of 
facilitating  the  spontaneous  ingress  of  air,  but  this  accident  failed  to  occur. 
Air  was  injected,  at  intervals  of  eight  minutes,  in  quantities  of  30  c.  cm  each, 
until  the  enormous  amount  of  480  c.  cm.  had  been  introduced.  After  the  first 
injection  nothing  was  observed  that  indicated  the  presence  of  air  in  the  veins 
or  the  heart.  After  the  second  dose  a  slight  splashing  sound  could  be  heard 
over  the  cardiac  region,  which  became  louder  and  more  distinct  as  the  amount 
of  air  in  the  right  side  of  the  heart  increased.  The  first  serious  symptoms 
observed  were  a  tumultuous  action  of  the  heart  and  difficulty  in  breathing, 
which  became  aggravated  by  every  succeeding  injection. 

Towards  the  end  of  the  experiment,  which  lasted  nearly  two  hours,  the 
animal  was  attacked,  at  short  intervals,  by  general  convulsive  movements. 
After  the  suspension  of  respiration  the  heart's  action  became  very  slow  and 
feeble,  and  at  times  irregular.  The  immediate  cause  of  death  was  plainly  due 
to  asphyxia,  as  manifested  by  the  great  dyspnoea  and  the  cyanotic  hue  of  all 
visible  mucous  surfaces.  On  examination  after  death,  a  few  air-bubbles  and 
only  a  small  amount  of  dark  blood  were  found  in  the  left  ventricle.  The  right 
ventricle  was  arrested  in  the  diastole  and  contained  a  large  quantity  of  very 
dark,  almost  black,  spumous  blood.  Air-bubbles  were  found  in  a  number  of 
distant  arteries  of  small  aize. 

Experiment  2.  Adult,  large  cat.  In  this  instance  the  cannula  was  intro- 
duced and  tied  in  the  left  jugular  vein.  The  heart  was  exposed  before  the 
injection  was  made  with  a  view  of  observing  directly  the  effects  produced  by 
sudden  inflation  of  the  right  cavities  of  the  heart.  Before  the  air  was  intro- 
duced, the  heart  contracted  regularly — artificial  respirations  being  made  for 
the  purpose  of  preventing  death  by  asphyxia.  As  soon  as  the  right  side  of  the 
heart  was  distended  by  the  air,  the  left  auricle  and  both  ventricles  ceased  to 
contract,  while  the  right  auricle  continued  to  pulsate.  The  pulsations  were 
feeble  and  irregular.  The  coronary  veins  became  filled  with  air-bubbles,  pre- 
senting the  appearance  of  a  rosary.  On  opening  the  superior  vena  cava,  air 
and  frothy  blood  escaped,  the  right  side  of  the  heart  collapsed,  and  all 
chambers  of  the  heart  commenced  to  contract  regularly  and  with  considerable 
force.  The  pulsations  continued  for  fifteen  to  twenty  minutes,  becoming  more 
feeble  and  irregular  and  intermittent  towards  the  last.  After  death  air  was 
found  in  both  vena?  cava?  and  the  iliac  veins.  The  left  ventricle  was  completely 
empty.  In  this  case,  owing  to  the  small  size  of  the  heart  and  the  large  amount 
of  air  introduced,  the  contractions  of  the  right  ventricle  were  arrested  in  the 
diastole,  while  respiration  continued.  Death  took  place  suddenly  from 
mechanical  over-distention  of  the  heart. 

Exjieriment  3.  Dog,  weight  sixty-five  pounds.  Injected  30  c.  cm.  of  air 
into  the  left  jugular  vein.  Churning  sounds  over  cardiac  region  loud  and 
distinct.  Heart's  action  became  very  tumultuous  and  intermittent.  Respira- 
tions superficial  and  rapid.  The  animal  was  bled  from  the  distal  end  of  the 
jugular  vein  to    the  amount   of    four  ounces,  whereupon    the    heart's  action 


254  EXPERIMENTAL  SURGERY. 

became  regular  and  the  respirations  diminished  in  frequency.  The  vein  was 
divided  completely  and  both  ends  were  tied  with  fine  catgut  ligatures,  the 
wound  being  closed  in  the  usual  manner.  For  a  number  of  days  the  dog 
appeared  quite  unwell,  showed  no  disposition  to  eat,  and  acted  very  stupidly, 
being  inclined  to  sleep  most  of  the  time.  Subsequently  he  recovered  com- 
pletely. In  this  case  the  intravascular  pressure  was  promptly  relieved  by  free 
bleeding,  which  enabled  the  heart  to  force  the  air  through  the  pulmonary  into 
the  general  circulation.  The  stupid  condition  of  the  animal  was  undoubtedly 
owing  to  embolism  of  the  cerebral  vessels,  which  disappeared  after  the  disap- 
pearance of  the  air-emboli  by  absorption. 

Experiment  4.  Adult,  medium-sized  cat.  Injected  15  c.  cm.  of  air  into 
left  jugular  vein.  Heart's  action  arrested  at  once.  The  respirations,  which 
were  irregular,  ceased  a  few  moments  later.  The  chest  was  opened  at  once. 
The  right  side  of  the  heart  was  found  enormously  dilated  and  almost  motion- 
less. Coronary  veins  filled  with  air.  The  right  ventricle  was  punctured  with 
the  needle  of  an  aspirator  and  its  contents  withdrawn,  when  the  pulsations 
were  re-established.  The  ventricle  was  again  inflated  through  the  needle  of  the 
aspirator.  Five  minutes  after  this  injection  the  pulsations  numbered  about 
250  per  minute.  Five  minutes  later  the  left  auricle  ceased  to  contract,  the 
movements  of  the  right  being  irregular  and  about  80  to  the  minute.  After  the 
lapse  of  another  five  minutes  the  pulsations  of  the  ventricles  were  only  17  a 
minute  and  a  little  later  all  movements  ceased.  This  experiment  demonstrates 
that  the  arrest  of  the  heart's  action  was  due  to  mechanical  over-distention,  as 
aspiration  of  the  right  ventricle  was  followed  by  regular  and  strong  contrac- 
tions in  all  cavities  of  the  heart.  The  contractions  were  not  the  result  of 
the  mere  mechanical  irritation  of  the  heart  by  the  puncture,  as  other  and 
equally  severe  irritants  had  been  previously  applied  without  producing  any 
effect. 

Experiment  5.  Dog,  weight  thirty-five  pounds.  Before  operation,  respi- 
rations 40,  pulse  140.  Injected  20  c.  cm.  of  air  into  right  jugular  vein. 
Convulsions  followed,  which  lasted  for  about  two  minutes.  Respiration  rapid 
and  stertorous.  Pulse  300.  After  five  minutes  the  animal  made  repeated 
attempts  to  get  up  and  walk,  but  invariably  fell  down  on  account  of  imperfect 
control  over  the  movements,  or  paralysis  of  the  posterior  extremities.  Half 
an  hour  later  the  animal  was  able  to  walk  but  appeared  very  feeble.  Pulse 
1L'4.  respirations  somewhat  accelerated.  Recovery  was  complete.  In  this 
case  the  equilibrium  of  the  circulation  was  soon  restored,  and  the  air  in  the 
right  side  of  the  heart  passed  through  the  pulmonary  into  the  general  circula- 
tion in  a  very  short  time,  as  was  evident  from  the  presence  of  symptoms 
indicative  of  embolism  of  some  of  the  vessels  in  the  cerebro-spinal  centers. 

Experiment  6.  Dog,  weight  seventy -five  pounds.  Injected  60  c.  cm.  of  air 
into  the  right  jugular  vein.  Churning  sounds  loud  and  distinct;  heart's 
action  labored.  Respirations  exceedingly  rapid,  later  stertorous.  The  animal 
recovered  rapidly  from  the  immediate  effects  of  the  air-embolism,  and  was 
soon  as  well  as  before  the  operation. 


EXPERIMENTS   ON    VENOUS  AIR   EMBOLISM.  255 

Remarks. — These  experiments  tend  to  prove  the  following 
statements : 

1.  A  small  amount  of  air  in  the  right  side  of  the  heart  in  a 
healthy  animal  gives  rise  only  to  temporary  symptoms  referable  to 
the  heart's  action  and  the  pulmonary  circulation. 

2.  When  air  has  been  introduced  into  the  right  side  of  the 
heart  in  such  quantities  as  not  to  arrest  the  contractions  of  the  heart 
at  once,  it  is  forced  through  the  pulmonary  capillaries  into  the  left 
side  of  the  heart  by  the  contractions  of  the  right  ventricle. 

3.  The  danger  attending  the  insufflation  of  air  into  veins  is 
proportionate  to  the  amount  of  air  introduced,  as  well  as  to  the 
capacity  of  the  right  ventricle  to  resist  intra-cardiac  pressure. 

4.  When  a  fatal  dose  of  air  has  been  introduced  into  the 
venous  circulation,  death  takes  place  almost  instantaneously  from 
arrest  of  the  heart's  action,  or  later  from  suffocation. 

5.  Spontaneous  ingress  of  air  into  a  wounded,  healthy  jugular 
vein  never  occurred  in  these  experiments,  and  must  be  considered 
almost  a  physical  impossibility,  as  the  resilient  walls  of  the  wounded 
vein  collapse  readily  when  exposed  to  atmospheric  pressure. 

Dogs  weighing  about  thirty  pounds  would  usually  recover  in  a 
short  time  after  an  injection  of  thirty  cubic  centimeters  of  air,  while 
double  that  amount  generally  constituted  a  fatal  dose.  Sheep 
required  a  proportionally  larger  dose  to  produce  a  fatal  result. 
These  experiments  also  tend  to  prove  that  animals  of  the  same  kind 
and  species  do  not  manifest  the  same  degree  of  tolerance  to  the 
presence  of  air  in  veins.  Young  animals  succumb  more  readily  to 
its  effects;  in  the  adult  animal  the  degree  of  tolerance  depends  on 
the  development  and  contractile  power  of  the  right  ventricle.  In  all 
cases  where  life  was  prolonged  for  a  considerable  length  of  time 
after  the  injection  of  air  was  made,  and  the  ventricular  contractions 
were  not  much  impaired,  bubbles  of  air  were  found  in  the  left  side 
of  the  heart,  showing  conclusively  that  the  air  must  have  passed 
from  the  right  ventricle  through  the  pulmonary  capillaries. 

In  experiments  8  and  5  the  well-marked  cerebral  disturbances 
were  undoubtedly  produced  by  secondary  air-embolism  of  the  vessels 
of  the  brain  and  spinal  cord,  since  these  disturbances  disappeared 
after  the  removal  of  the  emboli  by  absorption.  When  the  same 
amount  of  air  was  administered  in  one  dose,  it  always  proved  more 
dangerous  than  when  injected  in  divided  doses.     This  simply  means, 


256  EXPERIMENTAL  SURGERY. 

that  during  the  interval  between  the  injections,  sufficient  time  had 
elapsed  for  the  right  ventricle  to  force  at  least  a  portion  of  the  air 
through  the  pulmonary  capillaries  into  the  general  circulation;  thus 
preventing  for  a  time  at  least  a  fatal  degree  of  intra-cardiac  pressure. 
The  greater  the  development  of  the  right  ventricle,  the  greater  the 
tolerance  of  the  animal  to  the  presence  of  air  in  veins.  This  state- 
ment is  well  exemplified  by  the  fact  that  in  horses  a  larger  amount 
of  air  is  required  to  produce  death,  while  in  dogs  a  much  smaller 
proportionate  dose  will  result  in  death.  This  is  because  in  the 
former  animals  the  right  ventricle,  from  its  proportionately  greater 
strength,  is  more  competent  to  perform  an  additional  task. 

If  death  followed  immediately  after  the  injection,  the  dose  was 
usually  a  large  one,  the  heart's  action  having  been  suspended  before 
respiration  ceased,  and  on  post-mortem  examination  the  right  ven- 
tricle and  auricle  were  always  found  over-distended  and  tympanitic, 
containing  a  moderate  amount  of  blood  not  intimately  mixed  with  a 
large  amount  of  air,  while  the  left  side  of  the  heart  was  nearly  or 
completely  empty.  If  death  occurred  some  time  after  the  injection, 
great  dyspnoea  was  observed,  lividity  of  the  mucous  membranes, 
tumultuous  action  of  the  heart,  and  cessation  of  respiration  prior  to 
stoppage  of  the  action  of  the  heart ;  showing  conclusively  that  death 
took  place  from  carbonic  acid  intoxication.  In  these  cases  the 
necropsy  revealed  a  lesser  degree  of  distention  of  the  right  chambers 
of  the  heart,  which  invariably  contained  spumous  blood  or  blood 
intimately  mixed  with  air. 

The  pulmonary  artery  and  its  branches  were  filled  with  air  and 
spumous  blood,  and  bubbles  of  air  and  a  small  quantity  of  blood 
were  present  in  the  left  ventricle.  In  opening  the  jugular  vein  I 
have  always  noticed  that  the  vessel  would  promptly  collapse  as  soon 
as  haemorrhage  ceased,  being  transformed  into  a  pale,  round  cord,  in 
which  the  wound  could  be  found  only  with  great  difficulty.  Air  was 
never  seen  to  enter,  even  if  the  wound  and  a  portion  of  the  vein  were 
kept  patent  with  forceps  or  a  rubber-tube. 

I  frequently  arrested  the  column  of  blood  in  the  vein  by  apply- 
ing a  compressing  forceps  above,  and  opening  the  vessel  below,  thus 
creating  a  favorable  condition  for  the  spontaneous  entrance  of  air, 
but  the  result  remained  the  same.  It  is  therefore  only  reasonable 
to  assume  that  air  will  enter  spontaneously  only  in  case  a  vein  near 
the  heart  is  wounded,  the  walls  of  which  are  prevented  from  collaps- 


EXPERIMENTS   ON  ARTERIAL   AIR-EMBOLISM.  257 

ing  by  fixation  of  its  tunics  to  adjacent,  unyielding  structures,  or 
in  case  the  vein-walls  themselves  have  lost  their  resiliency  by 
previous  pathological  changes. 

XII.    Experiments  on  Arterial  Air-Embolism. 

Experiment  1.  Medium-sized  dog.  The  left  carotid  artery  was  exposed 
and  isolated,  and  two  haemostatic  forceps  applied  about  two  inches  apart. 
The  artery  was  divided  between  them,  and  the  proximal  end  secured  by  a  liga- 
ture. Into  the  distal  end  the  cannula  of  the  injecting  bulb  was  introduced 
and  fastened  with  a  ligature.  When  the  animal  had  fully  recovered  from  the 
anaesthetic,  the  forceps  were  removed,  and  80  c.  cm.  of  air  were  injected  at 
once  and  with  considerable  force;  the  cannula  was  then  removed  and  the 
artery  ligated.  The  animal  collapsed  almost  instantaneously,  and  respiration 
was  suspended  for  nearly  two  minutes.  The  animal  appeared  motionless  and 
in  a  condition  of  profound  stupor.  Heart's  action  tumultuous  and  very  rapid. 
Two  minutes  after  the  injection  churning  sounds  were  audible  over  the  cardiac 
region.  When  respiration  was  re-established  the  movements  of  the  chest  were 
slow  and  irregular,  gradually  becoming  slower  and  slower  until,  after  about 
fifty  attempts,  they  ceased  entirely.  The  limbs  were  rigid,  and  the  trunk  in  a 
position  of  opisthotonos.  The  heart  continued  to  contract  for  about  two 
minutes  after  respiration  had  ceased. 

All  vessels  leading  to  and  from  the  heart  were  carefully  ligated,  and  the 
organ  removed  and  examined  under  water.  The  coronary  veins  contained 
bubbles  of  air.  All  cavities  of  the  heart  contained  air,  the  largest  amount 
being  found  in  the  left  auricle.  Coagula  were  present  in  all  of  the  chambers, 
except  in  the  left  auricle.  The  circle  of  Willis  was  distended  with  air,  as  were 
many  of  the  smaller  vessels  of  the  brain  and  its  membranes.  The  cerebral 
vessels  were  gorged  with  dark  blood.  The  air  injected  into  the  carotid  artery 
had  evidently  passed  directly  through  the  cerebral  capillaries  into  the  venous 
circulation,  giving  rise  to  venous  and  general  air-embolism.  In  the  begin- 
ning, respiration  was  immediately  suspended  from  temporary  suspension  of 
innervation,  but  was  re-established  as  soon  as  the  amount  of  air  in  the  cerebral 
vessels  had  lessened  sufficiently  to  allow  a  better  blood  supply.  It,  however, 
ceased  definitely  under  symptoms  expressive  of  extensive  embolism  of  the 
pulmonary  artery. 

Experiment  2.  Sheep,  weight  ninety  pounds.  Left  carotid  artery  pre- 
pared as  in  previous  experiment,  only  that  the  air  was  injected  in  a  central 
direction,  towards  the  heart.  After  the  animal  had  recovered  almost  com- 
pletely from  the  effects  of  the  anaesthetic,  150  c.  cm.  of  air  were  thrown  in,  and 
the  proximal  end  of  the  artery  was  tied.  The  animal  was  at  once  thrown  into 
a  tetanic  state,  with  rigid  limbs  and  retracted  neck.  All  reflex  movements  and 
sensations  were  completely  suspended.  The  heart's  action  was  irregular  and 
tnmultllOUS,  and  over  the  cardiac  region  distinct  churning  sounds  were  heard. 
Respirations  exceedingly  rapid.  The  mucous  membranes  accessible  to  sight 
17 


258  EXPERIMENTAL   SURGERY. 

presented  a  strikingly  pale  and  anaemic  appearance.    Death  occurred  in  fifteen 
minutes,  respiration  ceasing  first. 

Examination  immediately  after  death  showed  the  right  ventricle  greatly 
distended  and  tympanitic  on  percussion.  It  contained  spumous  blood,  air,  and 
a  few  small  coagula.  Left  ventricle  contained  only  a  minute  quantity  of 
spumous  blood  and  fine  blood  clots  adherent  to  the  endocardium.  Air-emboli 
were  found  in  almost  all  vessels  throughout  the  body.  Coronary  arteries 
distended  with  air.  Jugular  veins  contained  more  air  than  blood.  Basilar 
artery  and  superior  longitudinal  sinus  contained  a  large  amount  of  air.  The 
tongue  and  other  distant  organs  extremely  ansemic. 

Although  this  large  quantity  of  air  was  thrown  directly  into  one  of  the 
large  arteries,  it  was  forced  into  the  smallest  vessels  and  through  the  capillaries 
into  the  veins  and  the  right  side  of  the  heart  by  the  powerful  contractions  of 
the  left  ventricle,  giving  origin  to  a  combination  of  symptoms  arising  from 
arterial  and  venous  embolism.  Death  was  finally  produced  in  a  similar  man- 
ner as  if  air  had  been  injected  directly  into  the  veins.  Some  of  the  air  had 
passed  all  the  capillaries  and  was  found  in  the  left  side  of  the  heart. 

Experiment  3.  Medium-sized  adult  cat.  With  a  view  to  ascertain  how 
soon  air  would  pass  through  the  capillary  vessels  after  injecting  it  into  the 
carotid  artery,  the  jugular  vein  on  the  opposite  side  was  opened  before  the 
injection  of  air  was  made.  About  15  c.  cm.  of  air  were  thrown  into  the 
carotid  artery  in  a  peripheral  direction.  The  animal  was  immediately  seized 
with  convulsions  and  died  in  less  than  a  minute.  Respiration  ceased  first. 
Air  was  seen  to  escape  from  the  wound  in  the  jugular  vein,  and  was  also  found 
in  nearly  all  of  the  vessels  throughout  the  body. 

On  opening  the  chest  the  right  side  of  the  heart  was  found  distended  to 
its  utmost,  and  tympanitic  on  percussion.  The  contractions  of  the  right 
auricle  were  twice  as  rapid  as  the  ventricular  contractions.  The  movements 
of  the  left  auricle  were  the  same  in  frequency  as  the  ventricular  pulsations. 
The  left  auricle  ceased  to  contract  seven  minutes  after  death.  The  right 
ventricle  was  puuctured  with  the  needle  of  an  aspirator,  and  its  contents 
removed,  whereupon  the  contractions  became  much  stronger. 

8  minutes  after  death,  ventricles  contracted  44  times  a  minute. 
10         "  "  "  "  "  30       "  " 

12         "  "  "•  "  "  16       "  " 

18         "  "  "  "  "  16       " 

29         "  "  "  "  "  6       " 

Then  all  contractions  ceased  and  could  not  be  restored  by  any  kind  of  irrita- 
tion. 

Right  auricle  ceased  beating  ten  minutes  after  death,  but  commenced  to 
contract  again  nineteen  minutes  later,  contracting  twenty-four  times  a  minute, 
the  movements  becoming  more  rapid  and  at  times  irregular  for  forty-eight 
minutes  after  death. 

Experiment  4.  Dog,  weight  thirty-five  pounds.  Into  the  left  carotid 
artery  60  c.  cm.  of  air  were  injected  in  a  proximal  direction.  The  animal  was 
seized  at  once  with  convulsions  of  a  tetanic  character,  with  the  limbs  extended 


EXPERIMENTS   ON  ARTERIAL   AIR-EMBOLISM.  259 

and  rigid.  Involuntary  discharges  from  bowels  and  bladder.  Sensation, 
motion,  and  reflex  actions  suspended.  Pupils  contracted.  Respirations  very 
rapid.  Heart's  action  slow  and  labored.  The  left  jugular  vein  was  opened 
and  four  ounces  of  blood  were  abstracted,  with  the  result  of  greatly  improv- 
ing the  heart's  action.  Both  vessels  were  ligated  and  the  wound  closed.  The 
animal  was  in  profound  stupor,  resembling  complete  anaethesia,  until  death 
occurred  two  hours  and  a  half  after  the  operation.  Half  an  hour  after  the 
injection  the  pulse  was  seventy-four,  respirations  forty- four  in  a  minute. 

On  opening  the  abdomen  the  large  veins  were  found  very  much  dilated 
and  contained  air.  Large  air  bubbles  were  also  found  in  the  pulmonary, 
internal  mammary,  and  coronary  arteries.  Small  thrombi  were  found  in 
many  of  the  ultimate  branches  of  the  pulmonary  artery.  The  right  side  of 
the  heart  was  distended  with  spumous  blood  and  air.  The  left  ventricle  was 
almost  completely  empty,  the  endocardial  lining  presenting  many  patches  of 
subserous  ecchymoses.  Nearly  all  the  vessels  of  the  brain,  and  the  longitud- 
inal sinus  contained  air.  Cerebral  and  meningeal  vessels  engorged  with  blood. 
The  animal  died  with  marked  symptoms  of  asphyxia.  The  tetanic  rigidity  of 
the  extremities  and  the  muscles  of  the  trunk,  as  well  as  the  remaining  promi- 
nent cerebral  symptoms,  were  produced  by  the  intense  cerebral  congestion, 
the  result  of  obstruction  of  some  of  the  smaller  vessels  by  air-emboli. 

Experiment  5.  Adult  dog,  weight  twenty  pounds.  Into  the  peripheral 
end  of  the  right  carotid  artery  20  c.  cm.  of  air  were  injected  after  the  animal 
had  completely  recovered  from  the  anaesthetic.  The  dog  collapsed  almost 
immediately  and  fell  to  the  floor,  perfectly  unconscious,  with  extended  and 
rigid  limbs.  Breathing  exceedingly  rapid,  but  gradually  growing  slower  as 
consciousness  returned.  When  the  animal  attempted  to  walk  it  staggered,  and 
frequently  fell,  having  apparently  lost  the  power  of  co-ordination  in  the  pos- 
terior extremities.  The  pupils,  at  first  dilated,  later  became  very  much  con- 
tracted. After  about  two  hours,  the  animal  walked  without  difficulty,  but 
respiration,  as  well  as  the  heart's  action,  continued  very  rapid.  The  next  day 
complete  recovery  had  taken  place.  Aside  from  the  cerebral  and  spinal  symp- 
toms, the  arterial  embolism  in  this  case  resulted  in  no  serious  consequences; 
the  most  threatening  symptoms  were  referable  to  venous  embolism,  showing 
that  most  of  the  air  had  passed  through  the  capillaries  into  the  venous  circu- 
lation and  right  side  of  the  heart. 

Experiment  6.  Adult  dog,  weight  twenty-two  pounds.  Right  carotid 
artery  exposed  and  4/»  c.  cm.  of  air  injected  towards  the  heart.  Involuntary 
discharges  from  bladder  and  rectum.  Pupils  dilated,  later  contracted. 
Animal  completely  unconscious,  anterior  limbs  extended  and  rigid,  slight 
opisthotonos,  breathing  mostly  abdominal.  Churning  sounds  over  heart  heard 
a  few  seconds  after  injection,  disappeared  after  eight  minutes.  Respiration 
ceased  five  minutes  after  the  air  was  injected,  but  was  again  restored  by  artifi- 
cial respiration  and  faradization  of  vagus  and  diaphragm.  Twenty-three 
minutes  after  the  injection,  pulse  128,  respirations  24;  fifty  minutes  after  injec- 
tion, pulse  105,  respirations  26;  fifty-two  minutes  after  injection,  pulse  120, 
respirations  20;  ninety  minutes  after  injection,  pulse  180,  respirations  20.     At 


260  EXPERIMENTAL   SURGERY. 

this  time  the  animal  made  several  unsuccessful  attempts  to  rise,  but  relapsed 
into  a  comatose  state,  which  continued  until  death,  which  occurred  fifteen  hours 
after  the  operation. 

At  the  post-mortem  examination  the  arteries  contained  a  good  deal  of 
dark,  almost  venous  blood  interspersed  with  bubbles  of  air.  Air  was  found 
in  the  uterine,  ovarian,  iliac  and  mesenteric  arteries  and  aorta;  also  in  both 
venae  cavae,  pulmonary  artery  and  veins.  Some  of  the  smallest  branches  of  the 
pulmonary  artery  were  obstructed  by  thrombi.  Right  ventricle  distended  with 
very  dark,  almost  black,  frothy  blood.  Left  ventricle  firmly  contracted  and 
almost  empty.  Left  auricle  contained  dark,  spumous  blood.  Coronary  arteries 
distended  with  air;  internal  mammary  arteries  and  veins  also  contained  air. 
Air  was  found  in  all  the  cerebral  vessels  and  sinuses,  which  were  distended 
with  dark  fluid  blood.  Vessels  of  spinal  cord  were  intensely  congested  and 
contained  numerous  air-bubbles.  The  mucous  membrane  of  the  stomach  pre- 
sented eleven  points  of  extravasation,  the  largest  being  circular  and  one  inch 
in  diameter. 

This  case  presented  the  most  diffuse  form  of  embolism,  the  emboli  being 
found  equally  numerous  and  diffuse  in  the  arterial  and  venous  systems.  The 
multiplicity  and  diffusion  can  be  satisfactorily  accounted  for  when  we  take 
into  consideration  the  large  amount  of  air  which  was  injected,  and  the  length 
of  time  which  had  elapsed  from  the  time  of  insufflation  until  death  occurred. 
The  post-mortem  appearances  plainly  indicated  that  death  was  produced  by 
slow  asphyxia.  The  primary  unconsciousness  and  stupor  were  induced  by 
the  acute  cerebral  ischsemia;  then  a  short  period  of  consciousness  returned,  as 
soon  as  the  collateral  circulation  in  the  brain  had  become  partially  established, 
when  the  animal  became  again  comatose  from  carbonic  acid  intoxication. 
The  abstraction  of  blood  relieved  the  threatening  symptoms  attending  the 
arterial  embolism,  but  failed  in  preventing  death  from  asphyxia  by  secondary 
venous  embolism. 

Experiment  7.  Dog,  weight  twenty-six  pounds.  Injected  15  c.  cm.  of  air 
into  the  right  carotid  artery  in  a  peripheral  direction.  The  animal  had  a 
slight  convulsion  and  remained  unconscious  for  about  twenty  minutes,  when 
it  rallied  and  was  able  to  walk  about  the  room  with  a  slightly  staggering  gait. 
No  complications  followed  the  operation.  In  this  instance  the  cerebral  symp- 
toms followed  the  insufflation  instantly,  but  owing  to  the  small  amount  of  air 
injected,  they  were  only  of  short  duration;  the  air,  passing  the  capillaries  in 
a  short  time,  entered  the  venuous  circulation  where  it  produced  temporary 
disturbances  in  the  pulmonary  circulation. 

Remarks. — Injection  of  air  into  arteries  produces  well-marked 
and  characteristic  symptoms  which  point  directly  to  a  disturbance 
in  the  circulation  of  the  brain  and  spinal  cord.  The  most  promi- 
nent symptoms  are:  Convulsions,  coma,  tetanic  rigidity  of  the  limbs 
and  extensor  muscles  of  the  back.  The  coma  resembles  complete 
and  profound  anaesthesia.     These  symptoms  follow  the  operation 


DIRECT  INTRA-CARDIAC  INSUFFLATION   OF  AIR.  261 

more  quickly  if  the  injection  is  made  in  a  peripheral  direction  toward 
thi*  brain.  If  the  animal  does  not  succumb  to  the  primary  effect  of 
the  air  upon  the  brain  and  medulla  oblongata,  a  series  of  symptoms 
succeed  which  announce  the  arrival  of  air  in  the  veins  and  right  side 
of  the  heart.  All  of  the  experiments  show  that  it  only  requires  a 
few  seconds  for  the  powerful  contractions  of  the  left  ventricle  to  force 
at  least  a  large  portion  of  the  air  through  the  capillaries  into  the 
veins. 

The  primary  effect  of  embolism  of  the  vessels  of  the  brain  is  to 
produce  acute  cerebral  ischa?mia,  the  intensity  of  which  depends  upon 
the  number  and  size  of  the  vessels  which  have  become  obstructed 
by  the  air-emboli.  This  anaemia  soon  gives  rise  to  intense  engorge- 
ment of  the  collateral  vessels  and  the  vessels  behind  the  point  of 
obstruction,  an  engorgement  to  such  an  extent  that  it  often  leads  to 
rupture  of  capillary  vessels  and  haemorrhage  into  the  paravascular 
tissues.  Unless  the  amount  of  air  injected  is  sufficient  to  prove 
rapidly  fatal  by  causing  suspension  of  the  functions  of  the  cerebro- 
spinal centers,  the  animal  dies  of  asphyxia  from  embolism  of  the 
pulmonary  artery,  the  same  as  though  the  air  had  been  injected 
directly  into  the  veins.  The  left  ventricle,  from  its  greater  thickness 
and,  in  consequence,  more  powerful  contractions  (as  compared  with 
the  right  ventricle),  is  better  adapted  to  overcome  the  increased 
resistance,  and  hence  the  air  is  rapidly  forced  through  the  systemic 
capillary  circulation  into  the  veins  and  right  side  of  the  heart.  On 
this  account  an  amount  of  air  injected  into  arteries  is  not  so  danger- 
ous as  the  same  amount  introduced  directly  into  veins,  as  a  certain 
percentage  of  it  never  reaches  the  veins  and  right  side  of  the  heart. 
Arterial  air-embolism  is  attended  by  an  additional  source  of  danger, 
which  consists  in  the  greater  tendency  to  coagulation  of  blood  in 
the  heart  and  vessels,  as  was  noted  in  several  experiments. 

XIII.    Direct  Intra-Cardiac  Insufflation  of  Air. 

These  experiments  were  made  with  a  view  of  demonstrating  by 
ocular  inspection,  that  sudden  over-distentron  of  the  cardiac  muscles 
will  arrest  their  contractility,  and  will  thus  produce  paralysis  of  the 
heart  in  the  diastole. 

Experiment  /.  Medium-sized  cat.  AfU-r  the  animal  was  fully  trader  the 
Lofluenc'e  <>f  ether,  respirations  and  heart's  action  being  normal,  the  chest  was 
rapidly  opened  and  tin-  heart   exposed.     Its  movements  remained    regular. 


262  EXPERIMENTAL   SURGERY. 

From  the  sudden  ingress  of  air  into  the  cavity  of  the  chest,  the  left  lung  col- 
lapsed, and  it  was  found  necessary,  in  order  to  prevent  asphyxia,  to  make 
artificial  respirations  on  the  right  side  of  the  chest.  The  pericardium  having 
been  opened,  the  right  ventricle  was  punctured  with  the  needle  of  an  aspirator, 
and  air  injected  in  sufficient  quantity  to  distend  the  right  chambers  of  the 
heart,  which  immediately  ceased  to  contract.  On  emptying  the  right  ventricle 
by  withdrawing  the  air  and  blood,  the  rhythmic  movements  of  the  organ  were 
restored.  These  manipulations  were  repeated  at  least  half  a  dozen  times,  and 
always  with  the  same  uniform  and  constant  results.  Half  an  hour  after  open- 
ing the  chest  all  movements  of  the  heart  ceased.  The  heart  was  now  removed 
and  immersed  in  water  at  a  temperature  of  105°  F.,  when  it  again  commenced 
to  pulsate  at  the  rate  of  120  beats  per  minute.  After  the  lapse  of  about  two 
minutes  it  was  removed  from  the -warm  water,  still  pulsating,  and  transferred 
to  cold  water,  when  all  movements  ceased  instantaneously,  and  all  efforts  to 
revive  them  proved  futile. 

Experiment  2.  Large  Maltese  cat.  Heart  exposed,  right  ventricle  punc- 
tured, and  11  c.  cm.  of  air  injected,  with  the  result  of  immediately  arresting 
the  pulsations  of  the  right  ventricle.  When  the  air  was  withdrawn,  the  regular 
movements  were  renewed.  This  experiment  was  repeated  on  both  ventricles 
eight  or  ten  times  in  the  course  of  half  an  hour  with  the  same  results.  The 
auricles  during  all  this  time  continued  to  contract.  Ten  minutes  after  the 
last  puncture  and  evacuation  the  ventricles  were  still  pulsating. 

Remarks. — Both  of  these  observations  support  the  statement 
that  sudden  over-distention  of  any  of  the  cavities  of  the  heart  by 
inflation  with  air,  will  arrest  its  movements  in  the  diastole,  and  that 
upon  the  removal  of  the  increased  intra-cardiac  pressure,  the  move- 
ments of  the  organ  are  restored.  It  was  found  that  by  continuing 
the  injecting  force  after  the  right  ventricle  had  become  distended, 
air  could  be  forced  readily  through  the  pulmonary  capillaries  into 
the  left  side  of  the  heart.  In  some  instances  one  of  the  cavities  of 
the  heart  was  kept  over- distended  and  at  rest  for  at  least  a  minute, 
and  yet  on  removing  its  contents  the  rhythmic  movements  were 
resumed. 

XI Y.    Aspiration  of  Right  Ventricle  for  Air-Embolism. 

Being  satisfied  of  the  fact  that  sudden  over-distention  of  the 
right  ventricle  may  and  does  produce  paralysis  in  the  diastole,  it 
appeared  reasonable  to  resort  to  some  direct  measure  in  removing 
the  cause  of  over-distention  in  grave  cases  of  venous  air-embolism. 
Puncturing  and  aspiration  of  the  right  ventricle  seemed  to  offer  the 
best  chances  for  accomplishing  this  object. 


ASPIRATION   OF  RIGHT    VENTRICLE.  263 

In  the  following  experiments  artificial,  venous  air-embolism  was 
produced  in  the  usual  way,  when  the  right  ventricle  was  punctured 
with  the  needle  of  an  aspirator  two  millimeters  in  diameter,  and  the 
contents  of  the  right  side  of  the  heart  removed  by  aspiration.  The 
region  over  the  heart  was  shaved  and  disinfected,  and  the  exact 
point  of  puncture  located  before  the  animal  was  anesthetized.  The 
needle  was  always  carefully  disinfected  by  passing  it  through 
the  flame  of  an  alcohol  lamp,  and  by  immersion  in  carbolized  water. 
When  the  puncture  was  made,  the  needle  was  advanced  first  only 
sufficiently  deep  to  bury  the  opening  in  its  point  beneath  the  tissues, 
when  a  vacuum  was  created  in  the  aspirator  so  that  the  entrance  of 
the  needle  into  the  ventricle  would  be  promptly  announced  by  the 
escape  of  spumous  blood.  By  following  this  precaution,  additional 
injury  to  the  heart,  by  pushing  the  needle  further  into  the  cavity  of 
the  ventricle,  was  avoided,  and  at  the  same  time  a  prompt  escape 
of  blood  was  secured. 

Experience  taught  me  that  it  was  very  important  not  to  push 
the  needle  too  deeply  into  the  cavity  of  the  ventricle;  not  only  for 
fear  of  inflicting  additional  injury  to  the  endocardial  lining  opposite 
the  point  of  entrance,  but  more  particularly  with  a  view  of  removing 
the  free  air  which  would  naturally  occupy  the  highest  point  in  the 
cavity,  if  it  was  not  intimately  mixed  with  the  blood.  The  needle 
was  always  directed  obliquely  from  below  upwards  for  the  twofold 
purpose  of  making  a  valvular  wound  in  the  ventricle  and  of  avoiding 
unnecessary  injury  to  the  endocardium. 

Experiment  1.  Dog,  weight  thirty-one  pounds.  60  c.  cm.  of  air  were 
injected  into  the  left  jugular  vein.  The  animal  was  seized  immediately  with 
a  convulsion,  followed  by  collapse.  Heart's  action  tumultuous.  Churning 
sounds  over  heart  were  distinctly  perceptible.  Respirations  rapid  and  super- 
ficial. Right  ventricle  was  punctured,  and  120  c.  cm.  of  spumous  blood  were 
withdrawn.  Pulsations  of  heart  became  more  feeble,  and  as  respirations  had 
ceased  and  could  not  be  restored,  the  chest  was  opened.  The  right  ventricle 
was  found  moderately  dilated  and  still  contracting.  Slight  contractions  of 
lower  portion  of  left  auricle.  Left  ventricle  contracted,  but  without  motion. 
The  needle  of  the  aspirator  was  then  introduced  into  the  right  auricle,  which 
was  distended  and  tympanitic.  After  emptying  it.  it  commenced  to  contract. 
All  contractions  ceased  hall  an  hour  after  the  air  was  introduced.  Faradic 
currents  had  no  effect  upon  the  heart  after  it  had  ceased  to  contract.  The 
pericardium  contained  air  in  considerable  quantity,  and  about  1  c.  cm.  of  fluid 

blood.    Ail'  was  found  in  the  ri^ht   side  of  t  lie  hea  rt.  t  he  left   ventricle,  coronary 
veins,  and  in  the  large  veins  in  the  in diale  vicinity  of  the  heart,      l'unct  are 


264  EXPERIMENTAL   SURGERY. 

about  an  inch  from  septum,  and  nearly  equidistant  between  the  apex  and 
base  of  heart.     No  injury  of  endocardium  on  opposite  side. 

Experiment  2.  Sheep,  weight  ninety-five  pounds.  Before  operation 
respirations  86,  pulse  140.  Injected  150  c.  cm.  of  air  into  left  jugular  vein, 
which  was  immediately  followed  by  convulsions  and  involuntary  discharges. 
Aspiration  of  right  ventricle  and  removal  of  150  c.  cm.  of  spumous  blood.  As 
the  animal  still  presented  an  asphyxiated  appearance,  the  ligature  was 
removed  from  the  distal  end  of  the  jugular  vein,  and  about  120  c.  cm.  of  blood 
were  allowed  to  escape.  The  animal  showed  no  signs  of  improvement,  and 
died  five  minutes  after  the  injection  was  made,  having  made  only  five 
attempts  at  respiration  during  the  time. 

Pericardium  contained  a  small  coagulum  and  a  few  bubbles  of  air.  Right 
ventricle,  distended  and  tympanitic,  contained  spumous  blood.  Two  punc- 
tures were  found  over  the  middle  of  the  right  ventricle  about  one-half  cm. 
apart;  the  second  was  made  during  the  convulsive  movements  of  the  animal, 
which  necessitated  a  partial  withdrawal  and  reintroduction  of  the  needle.  On 
the  inner  surface  each  puncture  was  hermetically  sealed  by  a  minute  thrombus 
which  projected  only  very  slightly  into  the  cavity  of  the  ventricle.  No  injury 
of  opposite  wall  of  ventricle.  In  the  left  ventricle,  which  was  firmly  con- 
tracted and  empty,  a  small  filiform  coagulum  projected  through  the  aortic 
orifice  into  the  aorta. 

Experiment  3.  Old  dog,  weight  forty  pounds.  Injected  45  c.  cm.  of  air 
into  left  jugular  vein.  Churning  sounds  over  heart  loud  and  distinct. 
Heart's  action  labored;  respirations  exceedingly  rapid.  No  convulsions,  but 
profound  coma  and  involuntary  discharges.  A  little  more  than  one  minute 
elapsed  between  the  introduction  of  air  and  aspiration,  during  which  time  the 
heart's  action  became  more  and  more  embarrassed,  and  all  of  the  symptoms 
became  so  grave,  that  death  seemed  unavoidable.  But  as  the  needle  reached 
the  heart,  a  slight  impulse  was  imparted  to  it  by  the  feeble  pulsations,  and 
120  c.  cm.  of  air  and  spumous  blood  were  removed.  The  heart's  action 
improved  immediately,  but  the  dyspnoea,  although  less  severe,  was  still  quite 
prominent.  Consequently  an  additional  120  c.  cm.  of  blood  were  allowed  to 
flow  from  the  peripheral  extremity  of  the  jugular  vein,  which  promptly 
relieved  the  urgent  symptoms.  Ten  minutes  after  the  injection,  respirations 
were  240  per  minute;  four  minutes  later  360,  and  after  eight  minutes  more, 
120.  After  forty  minutes  the  stupor  disappeared  and  the  animal  was  able  to 
walk.  One  hour  after  the  operation,  respirations  were  20  and  pulse  160  per 
minute.  At  this  time  the  animal  walked  home — a  distance  of  nearly  two  miles 
— and  subsequently  suffered  no  inconvenience  from  the  operation. 

Experiment  4.  Dog,  weight  seventy-five  pounds.  Injected  into  left 
jugular  vein  90  c.  cm.  of  air,  which  produced  intense  difficulty  in  breathing 
and  profound  stupor.  Sensation  and  reflex  movements  suspended.  Heart's 
action  exceedingly  feeble  and  rapid.  Churning  sounds  distinct.  The  aspirator 
and  needle  were  kept  in  readiness  to  be  used  promptly  on  the  approach  of 
symptoms  indicative  of  impending  death.  Two  minutes  after  the  injection 
the  animal  was  apparently  in  a  dying  condition,  upon  which  the  needle  was 


ASPIRATION   OF  RIGHT    VENTRICLE.  265 

plunged  into  the  right  ventricle,  and  from  its  rapid  oscillations  it  was  appar- 
ent that  the  heart's  action  had  not  entirely  ceased,  but  was  very  rapid  and 
feeble.  As  quickly  as  possible  180  c.  cm.  of  spumous  blood  were  withdrawn. 
which  promptly  relieved  the  most  urgent  symptoms;  but  as  the  respirations 
still  remained  rapid  and  labored,  the  ligature  was  removed  from  the  distal  end 
of  the  jugular  vein,  and  240  c.  cm.  of  blood  were  allowed  to  escape.  Eight 
minutes  after  the  injection,  the  churning  sounds  over  the  heart  were  still 
present,  but  faint.  Respirations  144;  pulse  130.  When  the  animal  had 
recovered  from  the  immediate  effects  of  the  operation,  it  was  noticed  that  the 
posterior  extremities  could  be  moved  only  with  difficulty,  the  gait  being  slow 
and  staggering.  For  twelve  hours  the  animal  was  dull  and  stupid,  remaining 
in  the  same  place  without  change  of  position.  The  drowsiness  continued  for 
thirty-six  hours,  after  which  the  animal  became  lively,  and  went  on  to  com- 
plete recovery  without  any  further  interruption.  In  this  case  it  was  apparent 
that  the  animal  would  have  died  from  the  large  volume  of  air  which  had  been 
injected,  but  for  timely  use  of  the  needle  and  aspirator.  Three  weeks  after 
the  experiment  the  animal,  being  in  perfect  health,  was  killed  by  an  arterial 
injection  of  air.  No  signs  of  pericarditis,  endocarditis,  or  myocarditis. 
Puncture  in  ventricle  indicated  by  a  minute  faint  cicatrix. 

Experiment  5.  Old  dog,  weight  twenty -five  pounds.  In  this  case  the 
aspirator  was  used  a  few  seconds  after  the  insufflation  of  air  was  made,  and 
the  result  shows  how  important  it  is  to  withdraw  the  air  from  the  ventricle 
before  it  has  had  time  to  escape  into  the  pulmonary  artery.  Immediately 
after  the  injection  of  90  c.  cm.  of  air  into  the  left  jugular  vein,  the  animal 
became  comatose.  Respiration  exceedingly  rapid  and  heart's  action  imper- 
ceptible. The  right  ventricle  was  punctured  at  once  and  as  soon  as  a  part  of  its 
contents  had  been  removed,  the  impulse  of  the  heart  was  imparted  to  the  needle, 
which  could  be  distinctly  seen  and  felt.  Spumous  blood  and  air  to  the  amount 
of  150  c.  cm.  were  withdrawn.  The  dog  rallied  rapidly  after  the  aspiration,  being 
able  to  walk  in  less  than  half  an  hour.  He  manifested  no  pain  or  discomfort 
from  the  air-embolism  or  operation.  The  volume  of  air  in  this  case  was  three 
times  as  large  as  in  the  previous  experiment,  when  the  weight  of  the  animals 
is  compared.  The  immediate  effects  of  the  air  were  expended  upon  the  heart, 
as  was  made  evident  by  the  temporary  cessation  of  its  pulsations,  and  yet 
death  was  prevented  by  the  prompt  removal  of  the  excessive  intra-cardiac 
pressure.  The  recovery  was  more  rapid  than  in  the  previous  cases,  from  the 
fact  that  not  so  much  air  had  passed  into  the  pulmonary  artery,  and  that  more 
was  removed  by  aspiration.  Two  weeks  later,  the  animal  being  in  perfect 
health,  60  c.  cm.  of  air  were  injected  into  the  right  jugular  vein,  which  pro- 
duced death  in  a  few  minutes,  showing  conclusively  that  the  recovery  after  the 
first  insufflation  was  due  to  the  aspiration.  Cicatrix  of  puncture  plainly 
visible.  No  signs  of  inflammation  in  the  pericardium,  endocardium,  oi  sub 
Stance  of  the  heart. 

K.rperiment  6.  Young  dog,  weight  twenty-eight  pounds.  In  this  experi- 
ment 120  c.  cm.  of  air  were  thrown  into  the  left  jugular  vein  in  divided  doses 
of  80  c.  cm.  each,  in  rapid  succession.     During  the  third  injection  the  animal 


266  EXPERIMENTAL   SURGERY. 

howled  and  became  comatose,  and  immediately  after  the  last  injection  the 
heart's  action  ceased  and  respirations  were  reduced  to  a  few  irregular  gasps. 
The  right  ventricle  was  punctured  and  120  c.  cm.  of  spumous  blood  and  air 
were  withdrawn,  without  producing  any  effect  upon  the  heart.  Artificial 
respiration  was  resorted  to  without  any  better  result.  The  chest  was  opened 
at  once.  The  pericardium  contained  4  c.  cm.  of  dark,  venous  blood  and  a  few 
air  bubbles.  Right  auricle  continued  to  contract  forty -eight  times  per  minute. 
Left  auricle  and  ventricle  were  distended  and  contained  spumous  blood.  The 
needle  had  punctured  the  right  auricle  instead  of  the  ventricle.  All  muscles, 
voluntary  and  involuntary,  reacted  promptly  to  the  faradic  current,  but  it  had 
not  the  slightest  effect  upon  the  heart. 

Experiment  7.  Young  dog,  weight  ten  pounds.  Injected  45  c.  cm.  of  air 
into  the  left  jugular  vein.  At  the  end  of  injection  the  dog  howled,  and  the 
heart's  action  ceased  almost  instantaneously.  The  right  ventricle  was  aspirated 
and  60  c.  cm.  of  spumous  blood  were  withdrawn.  Artificial  respiration  was 
performed  and  the  faradic  current  was  applied,  when  the  dog  made  a  few 
ineffectual  attempts  at  respiration  before  he  died.  On  examination  the  peri- 
cardium was  found  to  contain  a  slight  amount  of  dark  fluid  blood  and  a  few 
air-bubbles.  Both  auricles  contracted  about  forty-eight  times  in  a  minute. 
Right  ventricle  arrested  in  diastole.  Puncture  was  found  near  base  of 
ventricle.  Right  ventricle  was  again  aspirated,  and  the  faradic  current  was 
applied  directly  to  the  heart  and  the  needle,  without  producing  the  slightest 
effect.  Right  ventricle  and  pulmonary  artery  contained  spumous  blood. 
Left  ventricle  contracted  and  nearly  empty. 

Experiment  8.  Adult  dog,  weight  twenty-four  pounds.  Before  operation, 
respirations  80;  pulse  100  in  a  minute.  Injection  of  30  c.  cm.  of  air  into  left 
jugular  vein.  Immediately  after  injection  great  restlessness,  dyspnoea,  and 
tumultuous  action  of  heart.  Churning  sounds  loud  and  distinct.  Removed 
90  c.  cm.  of  spumous  blood  from  right  ventricle  by  aspiration.  After  the 
aspiration  the  improvement  in  respiration  and  pulse  was  marked.  Recovery 
complete,  and  not  attended  by  any  complications. 

Experiment  9.  Same  animal  as  in  experiment  3.  Animal  in  perfect 
health;  time  since  first  operation,  three  weeks.  Injection  of  40  c.  cm.  of  air 
into  right  jugular  vein.  Symptoms  the  same  as  before.  At  the  end  of  three 
minutes  and  a  half  the  pulsations  of  the  heart  ceased,  and  the  respirations 
were  nearly  suspended.  The  right  ventricle  was  now  punctured  and  250  c.  cm. 
of  spumous  blood  were  removed.  No  motion  imparted  to  needle.  Faradiza- 
tion and  artificial  respiration  were  ineffectual  in  restoring  either  the  heart's 
action  or  respiration.  On  examination  30  c.  cm.  of  dark  fluid  blood  were 
found  in  the  pericardium.  No  evidences  of  inflammation  from  former 
puncture.  Right  ventricle  moderately  distended  with  a  clot  of  spumous 
blood.  Point  of  second  puncture  one- half  inch  from  coronary  artery.  The 
location  of  first  puncture  was  marked  near  the  base  of  the  right  ventricle 
by  a  faint  minute  cicatrix  upon  the  pericardial  surface,  while  the  endo- 
cardium at  a  corresponding  point  showed  an  old  circumscribed  spot  of  ecchy- 
mosis,  but  no  evidences  of  inflammation.     Left  ventricle  contained  no  air 


ASPIRATION   OF  RIGHT    VENTRICLE.  261 

and   only    a    minute  quantity  of  fluid  blood.     Both   auricles   nearly   empty. 
Pulmonary  artery  contained  air  and  spumous  blood. 

This  experiment  demonstrates  positively  and  conclusively  the  value  of 
early  aspiration  of  the  right  ventricle  in  venous  air-embolism,  where  death  is 
threatened  by  over-distention  of  the  right  side  of  the  heart,  or  by  asphyxia. 
In  the  former  experiment  a  larger  amount  of  air  was  injected,  but  the  animal 
was  saved  by  an  early  aspiration,  by  which  a  large  amount  of  air  was  removed 
before  it  had  had  time  to  accumulate  in  the  pulmonary  artery.  It  also  illus- 
trates the  utter  uselessness  of  resorting  to  any  kind  of  mechanical  interference 
after  a  fatal  dose  of  air  has  once  passed  beyond  the  semilunar  valves  into  the 
pulmonary  artery.  In  such  instances  the  air  has  passed  beyond  our  reach, 
and  will  inevitably  lead  to  a  fatal  result  by  asphyxia. 

Experiment  10.  Adult  dog,  weight  eighteen  pounds.  Injection  of  60  c.  cm. 
of  air  into  left  jugular  vein.  Immediate  collapse;  churning  sounds  distinct. 
Aspiration  of  100  c.  cm.  of  air  and  spumous  blood  from  right  ventricle. 
Three  minutes  after  the  insufflation,  respiration  and  heart's  action  had  ceased. 
No  air  or  blood  found  in  the  pericardium.  Needle  puncture  equidistant 
between  base  and  apex  of  right  ventricle,  and  about  2  cm.  from  septum. 
Right  auricle  contracting  feebly  40  times  a  minute.  Right  ventricle  dilated, 
fibrillary  contractions  at  apex  only;  right  ventricle  and  pulmonary  artery 
contained  spumous  blood.  Left  auricle  and  ventricle  contained  only  a  slight 
amount  of  fluid  blood  and  a  few  air  bubbles. 

Remarks. — These  experiments  serve  to  illustrate  the  following 
interesting  points  in  pathology  and  surgery:  1.  The  heart  can  be 
punctured  with  a  perfectly  aseptic,  medium-sized  aspirator  needle 
without  any  great  immediate  or  remote  danger.  2.  Aspiration  of 
the  right  ventricle  for  venous  air-embolism,  when  done  early  enough 
(before  a  fatal  dose  of  air  has  been  forced  into  the  pulmonary 
artery),  must  be  considered  in  the  light  of  a  life-saving  operation. 

Although  the  needle  used  in  all  of  these  experiments  was  two 
millimeters  in  diameter,  the  haemorrhage  into  the  pericardium  was 
never  sufficient  in  quantity  to  prove  a  source  of  danger.  The  largest 
quantity  found  was  30  c.  cm.  (in  experiment  9).  In  a  number  of 
cases  no  trace  of  blood  was  found  in  the  pericardium.  Against  my 
expectations  the  same  observations  were  made1  in  regard  to  air.  In 
one  case  the  pericardium  contained  about  60  c.  cm.  of  air,  while  in 
most  cases  only  a  few  isolated  air-bubbles  were  seen,  while  in  others 
no  trace  of  it  could  be  found. 

In  all  cases  where  the  animal  survived  the  operation  and  was 
killed  from  a  few  days  U>  three  weeks  subsequently,  no  trace  of 
inflammation  could  be  found  either  in  serous  membranes,  muscular 
tissue,  or  adjacent  organs.     Even    adhesion   between  the   parietal 


268  EXPERIMENTAL   SURGERY. 

and  visceral  layers  of  the  pericardium  at  the  point  of  puncture  never 
occurred.  The  point  of  puncture  was  usually  marked  by  a  faint 
minute  cicatrix  in  the  visceral  pericardium,  unaccompanied  by  any 
pathological  changes  in  the  substance  of  the  heart.  We  must  take 
it  for  granted  that  if  effusion  of  blood  or  air  occurred  in  the  peri- 
cardium in  the  animals  which  recovered,  these  adventitious  sub- 
stances caused  no  irritation,  but  were  promptly  removed  by 
absorption. 

With  the  exception  of  the  subject  of  experiment  8,  it  may  be 
safely  assumed  that  all  of  the  animals  would  have  died  had  aspi- 
ration not  been  performed,  so  that  the  operation  saved  at  least  three 
of  the  animals  out  of  ten,  the  whole  number  of  experiments.  The 
most  conclusive  proof  of  this  statement  was  furnished  by  the  sub- 
jects of  experiments  3  and  5,  as  these  animals  died  during  subsequent 
experiments,  from  the  introduction  of  a  smaller  quantity  of  air. 

The  question  naturally  arises:  Why  were  not  all  of  the  animals 
saved  by  the  aspiration  ?  In  reply  it  may  be  stated  that  the  amount 
of  air  injected  in  most  instances  was  large,  more  than  was  necessary 
to  produce  a  fatal  result.  Another  element  of  failure  consisted  in 
the  postponement  of  the  aspiration  until  a  fatal  dose  of  air  had 
passed  beyond  the  reach  of  the  aspirator.  To  prevent  death  by  air- 
embolism,  it  is  essential  to  remove  the  air  from  the  right  ventricle  as 
soon  as  possible  after  its  entrance,  before  a  fatal  embolism  of  the 
pulmonary  artery  has  had  time  to  take  place.  In  some  of  the  expe- 
riments a  fatal  result  might  probably  have  been  prevented  by 
removing  a  larger  quantity  of  air  and  blood  with  the  aspirator,  as  in 
some  instances  the  condition  of  the  animal  was  improved  by  a 
subsequent  venesection  from  the  jugular  vein. 

XT.    Catheterization  and  Aspiration  of  Right  Auricle  for 
Tenons  Air-Embolism. 

In  grave  cases  of  accidental  air -embolism  it  would  be  a  desid- 
eratum to  be  in  possession  of  some  means,  by  which  the  air  could 
be  removed  directly  from  the  right  side  of  the  heart  in  the  shortest 
possible  space  of  time  and  with  the  simplest  instrument.  An  aspira- 
tor is  not  always  at  hand,  and  is  less  frequently  in  a  proper  condition 
to  be  used  on  such  short  notice.  It  appeared  to  me  that,  inasmuch 
as   the  accidental  introduction  of  air   usually  takes  place  through 


CATHETERIZATION   OF  RIGHT  AURICLE.  269 

wounds  in  one  of  the  jugular  veins,  a  catheter  might  be  introduced 
through  the  wound  into  the  vein,  and  from  there  passed  directly  into 
the  heart,  and  the  air  and  spumous  blood  withdrawn  through  it  by 
aspiration.  A  catheter  is  almost  always  at  hand,  and  its  introduction 
would  require  only  a  few  moments  of  time.  The  following  experi- 
ments were  made  to  test  the  feasibility  of  this  procedure : 

Experiment  J.  Adult  dog,  weight  twenty-four  pounds.  The  right  jugular 
vein  was  opened  and  60  c.  cm.  of  air  were  introduced  in  the  usual  way.  The 
breathing  became  very  difficult  and  the  heart's  action  labored.  The  animal 
was  comatose,  pupils  dilated.  As  soon  as  it  could  be  done,  a  No.  6  English 
scale,  gum  elastic  catheter,  which  had  previously  been  made  aseptic,  was  intro- 
duced into  the  wound,  and  passed  into  the  heart,  a  distance  of  15  cm.,  and 
with  an  exhausting  syringe  250  c.  cm.  of  air  and  spumous  blood  were  removed. 
The  animal  recovered  rapidly  from  the  immediate  effects  of  the  air-embolism 
and  operation,  and  subsequently  manifested  no  symptoms  of  disease. 

Experiment  ~'.  Young  dog.  weight  thirty  pounds.  Injected  100  c.  cm.  of 
air  into  left  jugular  vein.  The  heart's  action  ceased  almost  instantaneously. 
The  same  catheter  was  introduced  and  pushed  forward  a  distance  of  18  cm., 
and  about  120  c.  cm.  of  air  and  spumous  blood  withdrawn  by  the  mouth.  At 
this  time  respiration  ceased,  and  as  no  pulsations  of  the  heart  could  be  felt,  the 
chest  was  opened  at  once.  Fibrillary  contractions  of  right  ventricle,  which 
was  distended  and  tympanitic.  Left  auricle  and  ventricle  contracted  and 
motionless.  Right  auricle  contracted  regularly  80  times  a  minute.  Faradic 
and  galvanic  currents  had  no  effect  on  ventricles.  Right  auricle  responded  to 
a  slowly  interrupted  galvanic  current. 

The  catheter  was  again  introduced,  and  its  course  observed  as  it  entered 
the  right  auricle.  It  was  found  impossible  by  any  manipulation  to  pass  it 
from  the  auricle  into  the  ventricle.  In  every  instance  it  passed  from  the  right 
auricle  directly  into  the  inferior  vena  cava.  The  right  side  of  the  heart  was 
filled  with  water  to  test  the  possibility  of  removing  fluids  from  the  right 
auricle  without  introduction  of  the  catheter  into  the  chamber.  A  catheter 
with  an  open  extremity  was  used.  No  amount  of  suction  force  succeeded 
in  removing  any  of  the  fluid,  until  the  open  end  of  the  catheter  reached  the 
auricle,  when  both  chambers  could  be  readily  emptied.  As  long  as  the  end 
of  the  catheter  remained  in  the  vein,  the  walls  of  the  vein  in  front  of  the 
catheter  would  invariably  collapse  and  close  the  opening  in  the  catheter  com- 
pletely on  applying  suction  force. 

This  satisfied  me  that  in  order  to  remove  air  or  blood  from  the  right  side 
of  the  heart,  it  is  necessary  to  introduce  the  catheter  as  far  as  the  auricle.  It 
was  also  evident  that  in  case  the  catheter  was  introduced  too  far,  its  distal  end 
would  pass  into  the  inferior  vena  cava,  and  on  aspiration  only  venous  blood 
would  be  withdrawn,  not  air  and  spumous  blood  from  the  right  chambers  of  the 
heart,  for  the  removal  of  which  the  procedure  was  intended.  On  Opening  the 
right  side  of  the  heart,  a  large  spongy  clot  of  spumous  blood  was  found  in  1  he 
rij^ht  auricle,  which  extended  for  some  distance  into  the  ventricle.     Left  veil- 


270  EXPERIMENTAL  SURGERY. 

tricle  contained  only  a  small  amount  of  fluid  blood  and  a  few  air-bubbles.  As 
the  heart's  action  had  ceased  before  catheterization,  death  was  undoubtedly 
due  to  the  insufflation  of  air  and  not  to  the  formation  of  a  thrombus  in  the 
heart. 

Experiment  3.  Adult  dog,  weight  twenty  pounds.  Injected  30  c.  cm.  of 
air  into  right  jugular  vein.  Catheterization  and  aspiration  of  right  auricle, 
by  which  90  c.  cm.  of  air  and  spumous  blood  had  been  withdrawn,  when  cathe- 
ter became  impermeable  from  a  thrombus  in  its  interior  and  was  removed. 
Before  emptying  the  right  side  of  the  heart  the  animal  was  comatose;  breath- 
ing and  heart's  action  exceedingly  rapid.  After  aspiration,  rapid  improvement 
and  complete  recovery.  If  the  catheter  in  this  instance  had  been  permitted 
to  remain  longer  in  the  auricle,  the  thrombus  which  formed  in  the  interior  of 
the  instrument  would  undoubtedly  have  increased  rapidly,  and  would  have 
extended  to  the  auricle,  in  which  event  death  from  thrombosis  would  have 
been  unavoidable. 

Experiment  4.  Old  dog,  weight  forty  pounds.  Before  operation  respira- 
tions 16;  pulse  100  per  minute.  Injection  of  90  c.  cm.  of  air  into  left  jugular 
vein.  Passed  a  No.  5  Nelaton's  catheter  into  right  auricle,  a  distance  of  27 
cm.,  and  removed  250  c.  cm.  of  air  and  spumous  blood.  Immediately  after 
the  insufflation  the  animal  uttered  a  howl  and  became  comatose.  Pulse  250 
per  minute,  respirations  so  rapid  that  they  could  not  be  counted.  Seven 
minutes  after  catheterization  heart's  action  very  irregular,  tumultuous,  and 
about  three  hundred  beats  per  minute.  Two  minutes  later  respiration  ceased, 
after  which  the  heart's  action  became  slow  and  feeble,  and  ceased  a  few  seconds 
later.  Internal  mammary  and  coronary  veins  filled  with  air.  Left  side  of 
heart  contained  a  small  amount  of  bright  red,  frothy  blood.  Right  ventricle 
moderately  dilated,  showed  fibrillary  contractions.  Superior  and  inferior 
vena  cava,  right  auricle  and  ventricle  contained  a  continuous,  soft  thrombus, 
the  oldest  portion  of  which  corresponded,  to  the  superior  vena  cava.  The 
upper  portion  of  the  clot  in  the  inferior  vena  cava  contained  air.  Death  in 
this  instance  was  due  to  the  formation  of  a  thrombus. 

Experiment  5.  Adult  dog,  weight  twenty-five  pounds.  Injection  of  60 
c.  cm.  of  air  into  left  jugular  vein  produced  immediate  collapse,  distressing 
dyspnoea,  and  great  rapidity  and  irregularity  of  heart's  action.  The  dog 
howled  when  the  heart's  action  ceased,  and  respiration  became  gasping. 
Some  delay  was  experienced  in  the  introduction  of  the  catheter,  and  when  the 
instrument  was  in  place  all  signs  of  life  had  disappeared.  About  50  c.  cm.  of 
spumous  blood  were  withdrawn  without  any  signs  of  improvement.  Artificial 
respiration  and  faradization  were  resorted  to  without  producing  the  slightest 
impression.  On  opening  the  chest  it  was  observed  that  the  right  auricle 
contracted  about  30  times  a  minute.  Irregular  fibrillary  contractions  of  apex 
of  right  ventricle.  Right  side  of  heart  moderately  distended  with  spumous 
blood.     No  thrombus.     Left  ventricle  almost  empty. 

Experiment  6.  Adult  dog,  weight  fifteen  pounds.  InjectioD  of  60  c.  cm. 
of  air  into  right  jugular  vein.  In  this  case  the  catheter  was  connected  with  a 
rubber-tube  three  feet  in  length,  which  was  kept  under  water;  after  which  the 


CATHETERIZATION    OF  RIGHT   AURICLE. 


271 


instrument  was  pushed  along  the  jugular  vein  into  the  right  auricle.  The 
injection  of  air  was  followed  by  the  most  urgent  and  distressing  symptoms. 
Only  a  small  amount  of  dark  venous  blood  escaped  through  the  rubber-tube 
until  the  catheter  reached  the  right  auricle,  when  a  gush  of  spumous  blood 
escaped  from  the  tube  under  water.  As  the  blood  did  not  continue  to  escape, 
about  60  c.  cm.  of  spumous  blood  were  withdrawn.  After  the  aspiration  the 
symptoms  improved  rapidly,  and  within  twenty-five  minutes,  with  the  excep- 
tion of  a  slight  excess  in  the  respiratory  movements,  the  animal  appeared 
to  be  perfectly  well.  The  ultimate  recovery  was  complete  and  was  not 
disturbed  by  any  complications. 

Experiment  7 .  Adult  dog,  weight  forty-eight  pounds.  Before  operation 
pulse  150;  respirations  28.  Injection  of  120  c.  cm.  of  air  into  right  jugular 
vein.  The  animal  howled  and  collapsed.  Respirations  increased  at  once  to 
100  per  minute.  Heart's  action  tumultuous,  and  churning  sounds  loud  and 
distinct.  Passed  a  Nelaton's  catheter  into  the  right  auricle,  and  aspirated  360 
c.  cm.  of  air  and  spumous  blood.  No  signs  of  improvement  followed,  and  in 
fifteen  minutes  the  animal  was  dead.  At  the  post-mortem  examination  the 
internal  mammary  veins  were  found  distended  with  air.  Right  side  of  heart 
tympanitic  and  distended.  Slight  fibrillary  contractions  of  right  auricle. 
Apex  of  right  ventricle  contracted  regularly  22  times  in  a  minute.  Coronary 
veins  filled  with  air.  A  thrombus  had  formed,  which  extended  from  the 
superior  vena  cava  into  the  right  auricle,  ventricle,  and  for  a  distance  of  25 
cm.  into  the  inferior  vena  cava.  Pulmonary  artery  contained  no  thrombus, 
but  was  distended  with  air  and  spumous  blood.  Left  ventricle  contracted; 
contained  a  small  amount  of  fluid  blood  and  air-bubbles.  It  was  quite  evident 
that  the  thrombus  had  primarily  formed  around  the  catheter,  and  that  by  new 
additions  it  had  finally  reached  the  distal  portion  of  the  inferior  vena  cava. 
Death  was  produced  by  thrombosis. 

Remarks. — The  therapeutical  value  of  catheterization  and  aspi- 
ration of  the  right  auricle  for  air-embolism  is  made  apparent  by  the 
following  tabular  arrangement  of  the  experiments : 


No.  of 
experiment. 

Weight  of 
animal. 

Amount  of  air 
injected. 

Amount  of  nir 
and  blood 
removed. 

Result. 

Cause  of  death. 

1 
2 

24  pounds. 
30       " 

60  c.  cm. 
100       " 

250  c.  cm. 
120       " 

Recovery. 
Death. 

Thrombosis. 

3 
4 

20       " 
40       " 

30       " 

90       " 

90       " 

250       " 

Recovery. 
Death. 

Thrombosis. 

5 

25       " 

60       " 

50       " 

u 

Air-embolism. 

6 

7 

15       " 

48       " 

60       " 

120       " 

60       " 
360       " 

Recovery. 

Death. 

Thrombosis. 

From  this  table  it  will  be  seen  that  of  seven  animals  subjected 
to  the  operation,  three  recovered  and  four  died.  The  amount  of  air 
injected  in  the  subjects  of  experiments    1  and  (5  was  sufficient  to 


272  EXPERIMENTAL   SURGERY. 

destroy  life,  so  that  we  can  safely  assume  that  the  animals  would 
have  died,  but  for  the  speedy  resort  to  catheterization  and  aspiration. 
In  the  subject  of  experiment  3,  recovery  might  have  taken  place 
without  the  operation,  as  the  relative  quantity  of  air  was  much 
smaller.  In  the  four  fatal  cases  death  was  produced  only  once  from 
the  presence  of  air,  while  the  direct  cause  of  death  in  the  remaining 
three  cases  was  thrombosis.  All  possible  precautions  were  exercised 
to  prevent  this  accident.  The  catheter  was  made  aseptic  by  thorough 
cleansing  and  immersion  in  a  five  per  cent,  solution  of  carbolic  acid. 
Before  the  operation  the  instrument  was  kept  ready  for  use  in  an 
alkaline  solution,  of  the  temperature  of  the  body,  and  yet  this 
accident  happened  in  three  out  of  seven  cases. 

It  is  now  asserted  that  the  introduction  of  aseptic  bodies  into 
the  circulation  does  not  give  rise  to  thrombosis,  and  it  may  be  possi- 
ble that  some  of  the  instruments  used,  in  spite  of  the  pains  taken  to 
render  them  aseptic,  were  still  not  in  a  fit  condition  to  be  used  for 
such  a  purpose.  Catheterization  and  aspiration  of  the  right  auricle 
for  air-embolism  compare  favorably  with  puncture  and  aspiration  of 
the  right  ventricle  as  a  life-saving  procedure,  but  the  former  opera- 
tion is  more  dangerous  on  account  of  the  tendency  to  the  formation 
of  a  thrombus  within  or  around  the  catheter.  If  this  formation  of 
thrombus  could  be  avoided  with  certainty,  catheterization  and  aspi- 
ration of  the  right  auricle  would  recommend  itself  as  the  most 
expedient  and  reliable  therapeutic  agent  in  cases  where  life  is 
threatened  by  air-embolism. 

XTI.    Prophylactic  Treatment  of  Air-Embolism. 

As  clinical  experience  and  experimental  research  have  shown 
that  the  admission  of  air  into  veins  is  not  an  infrequent  occurrence 
and  has  often  resulted  in  death,  it  is  the  duty  of  the  surgeon  in 
extirpating  tumors  which  are  in  close  proximity  to  the  large  veins 
within  the  area  of  the  "  danger  zone,"  to  resort  to  measures  which 
will  prevent  the  ingress  of  air  in  case  a  vein  is  accidentally 
wounded.  The  following  precautionary  means  deserve  consider- 
ation:     1.    Position.      2.    Compression.      3.    Ligature.      4.   Aseptic 

tampon. 

I.    Position. 

Regular  respiratory  movements  of  the  chest  are  necessary  to 
maintain  the  equilibrium  between  the  arterial  and  venous  circulation, 


PROPHYLACTIC   TREATMENT   OF  AIR-EMBOLISM.  273 

and  should  always  be  secured  in  operating  in  close  proximity  to 
veins  at  the  base  of  the  neck;  as  during  a  sudden  deep  inspiration, 
the  direct  aspiratory  effect  of  respiration  in  the  veins  extends  to 
some  distance,  constituting  thus  the  direct  cause  of  entrance  of  air 
into  an  open  vein.  Before  anaesthetics  were  used,  Poisenille  advised 
that  the  patient  should  be  instructed  not  to  make  any  deep  inspira- 
tory movements  during  the  operation.  At  the  present  time  the  same 
object  is  better  obtained  by  keeping  the  patient  thoroughly  and  con- 
tinuously under  the  influence  of  the  anaesthetic.  Gerdy  aimed  to 
prevent  the  aspiratory  effect  of  respiration  by  recommending  com- 
pression of  the  thorax,  but  the  advice  is  more  useful  in  theory  than 
in  practice,  as  suspension  of  the  thoracic  movements  for  any  length 
of  time,  would  necessarily  interfere  with  respiration  and  cause  death 
by  asphyxia. 

The  venous  circulation  is  greatly  influenced  by  position.  In 
the  elevated  position  the  blood  gravitates  towards  the  heart  and  the 
veins  are  emptied.  If,  while  in  this  position,  a  vein  is  wounded, 
and  the  walls  of  the  vessel  do  not  collapse  on  account  of  some 
anatomical  peculiarities,  or  from  rigidity  of  the  vein  wall  itself, 
due  to  pathological  changes,  a  vacuum  is  formed  and  air  enters. 
The  entrance  of  air  into  a  vein  distended  with  blood  is  a  physical 
impossibility.  In  reading  the  clinical  histories  of  cases  where  air 
entered  veins  during  operations,  we  are  met  by  the  fact  that  in 
almost  all  of  the  cases,  the  wounding  of  the  vein  was  not  followed  by 
any  considerable  loss  of  blood,  and  we  are  usually  told  that  the  air 
entered  almost  immediately  after  the  vessel  was  injured,  which 
would  indicate  that  the  vein  was  empty  or  nearly  so  at  the  time  it 
was  wounded.  In  a  number  of  cases  the  bloodless  condition  of  the 
vein  attracted  the  attention  of  the  operator,  and  is  particularly 
emphasized  in  the  description  of  the  cases.  As  long  as  the  interior 
of  a  vein  and  the  lumen  of  a  wound  in  its  walls  are  occupied  by  a 
continuous  stream  of  blood  there  is  no  danger  that  air  will  be 
admitted. 

Statistics  tend  to  show  that  the  accidental  admission  of  air  into 
veins  was  more  frequent  before  anaesthetics  were  used,  a  fact  which 
we  can  only  explain  by  assuming  that  the  patients  were  then  usually 
placed  in  a  sitting  or  semi -recumbent  position  during  the  operation, 
positions  favorable  to  the  return  of  venous  blood  from  the  cervical 
region.    On  the  other  hand,  the  safe  administration  of  an  anaesthetic 


274  EXPERIMENTAL   SURGERY. 

necessitates  the  horizontal  position,  in  which  the  veins  of  the  neck 
become  distended  with  blood.  In  the  former  instance,  the  return  of 
venous  blood  in  the  vessels  of  the  upper  portion  of  the  body  was 
favored  by  the  elevated  position,  and  the  vacuity  thus  produced  in 
the  veins  constituted  the  most  important  and  potent  factor  in 
determining  the  entrance  of  air.  In  the  horizontal  position,  the 
veins  of  the  neck  are  never  empty,  and  to  effect  entrance  of  air  the 
exciting  cause  must  operate  with  increased  intensity.  On  this 
account  the  horizontal  or  dependent  position  of  the  region  of  the 
body  to  be  operated  upon,  recommends  itself  as  the  simplest  prophy- 
lactic measure  against  the  accidental  entrance  of  air  into  wounded 
veins.  This  position  increases  the  risk  of  haemorrhage  from  the 
injured  vein,  but  this  accident  in  its  immediate  effects  is  less 
disastrous  to  the  patient  and  more  readily  under  the  control  of  the 
surgeon  than  air-embolism. 

2.     Compression. 

Compression  of  a  vein  between  the  seat  of  operation  and  the 
heart,  for  the  purpose  of  guarding  against  the  entrance  of  air,  may 
be  divided  into  intermediate  and  direct.  Intermediate  compression  is 
only  applicable  in  cases  where  the  external  jugular  vein  is  in  danger 
of  being  wounded.  If  the  tumor  to  be  extirpated  is  not  located  too 
low  in  the  region  of  the  neck,  uninterrupted  digital  compression  of 
the  external  jugular  vein  just  above  the  clavicle  can  be  relied  upon 
to  prevent  entrance  of  air  through  this  vessel.  The  internal  jugular 
and  axillary  veins  are  so  deeply  situated  that  intermediate  digital 
compression  cannot  be  relied  upon  in  the  prevention  of  air-embolism, 
consequently  direct  compression  should  be  resorted  to  whenever  it 
becomes  necessary  to  guard  against  this  accident.  Warren  recom- 
mended that,  in  the  extirpation  of  tumors  which  are  in  close  proximity 
to  the  large  veins  of  the  neck  and  axilla,  the  separation  of  the  pedicle 
should  be  reserved  until  the  last,  in  order  to  enable  the  operator  to 
compress  the  vein  between  the  seat  of  operation  and  the  heart  more 
effectually,  should  the  vessel  be  injured  during  the  operation. 

Langenbeck  advised  that  the  vein  on  the  distal  and  proximal 
sides  of  the  tumor  should  be  exposed  to  view  as  a  preliminary 
measure  before  attempting  the  removal  of  the  tumor,  in  order  to 
facilitate  direct  compression  in  case  the  vessel  should  be  opened 
during  the  dissection.     The  adoption  of  either  of  these  precautions 


PROPHYLACTIC    TREATMENT   OF  AIR-EMBOLISM.  275 

would  successfully  prevent  a  second  ingress  of  air,  but  would  not 
protect  the  patient  against  the  dangers  arising  from  the  first  dose. 
Permanent  central  compression  augments  the  danger  of  wounding 
the  vein,  from  the  turgidity  of  the  vessel  which  it  produces,  while 
distal  compression  would  be  attended  by  the  same  risk,  only  in  an 
opposite  way,  by  rendering  the  vessel  empty  and  consequently  more 
difficult  of  recognition.  If  the  attachments  of  the  tumor  to  the  vein 
are  of  such  a  nature  that  they  can  be  separated  without  great  danger 
of  injuring  the  vessel,  then  the  vein  should  be  isolated'  on  the 
proximal  side  and  the  vessel  compressed  with  a  haemostatic  forceps, 
which  will  afford  greater  safety  than  digital  compression;  at  the 
same  time  the  field  of  operation  is  not  obscured  and  narrowed  by  the 
fingers  and  hand  of  the  assistant,  an  item  of  great  importance  in 
operating  in  the  regions  of  the  neck  or  axillary  space. 

Injury  of  the  vein  in  such  instances  will  be  promptly  announced 
by  haemorrhage  from  the  distal  portion,  but  the  entrance  of  air  into 
the  right  ventricle  is  made  impossible  by  the  prophylactic  compres- 
sion of  the  vessel  between  the  seat  of  operation  and  the  heart. 
Should  the  vein  be  wounded,  any  further  ill  effects  arising  from  this 
accident  can  be  prevented  by  applying  a  lateral  ligature,  or  by  tying 
both  ends  of  the  vein  according  to  the  size  of  the  wound,  before 
removing  the  compressing  forceps.  In  all  operations  where  any  of 
the  large  veins  are  in  danger  of  being  wounded,  the  position  of  the 
parts  should  be  such  as  to  retain  as  nearly  as  possible  their  normal 
anatomical  relations.  The  operator  should  make  haste  slowly,  and 
identify  every  structure  before  using  cutting  instruments.  In  extir- 
pating tumors  that  are  deeply  situated,  the  external  incision  should 
always  be  large,  so  sis  to  afford  free  access  to  the  base  or  deepest 
portion  of  the  growth  to  be  removed.  A  pair  of  Billroth'  s  retractors 
will  do  good  service  during  the  deep  dissection. 

Hamorrhage  must  be  carefully  arrested  as  it  occurs,  in  order  to 
enable  the  surgeon  to  see  what  he  is  doing.  Isolation  of  the  vein 
from  the  tumor  must  be  accomplished  by  the  use  of  blunt  instru- 
ments, and  all  firmer  attachments  should  be  carefully  examined  and 
identified  before  using  the  knife  or  scissors.  As  it  is  usually  impos- 
sible, or,  at  any  rate,  impracticable  to  find  the  vein  in  the  tumor  or 
its  immediate  vicinity,  the  rule  should  always  be  followed  to  expose 
the  vessel  for  some  distance  from  the  tumor  on  the  proximal  side. 


276  EXPERIMENTAL  SURGERY. 

and  then  follow  it  by  carefully  separating  the  attached  tissues 
by  means  of  blunt  instruments. 

Under  antiseptic  precautions  the  jugular  vein  can  be  isolated  for 
a  great  distance  without  fear  of  compromising  the  vitality  of  its 
tissues  or  causing  thrombosis.  When  a  tumor  is  attached  to  the 
jugular  vein  it  is  a  dangerous  practice  to  make  traction  on  the  tumor 
for  the  purpose  of  facilitating  the  deep  dissection,  as  this  procedure 
will  disturb  the  normal  anatomical  relations  of  the  vessel,  and  thus 
expose  it  to  greater  risk  of  being  wounded.  Free  access  to  the  base 
of  the  tumor  must  be  secured  without  displacing  the  subjacent  vein. 
As  soon  as  the  tumor  has  been  isolated  from  the  surrounding  tissues, 
a  thorough  examination  should  be  made  of  the  extent  of  its  base  and 
its  relations  to  the  subjacent  vein  before  proceeding  any  further  with 
the  dissection. 

If  the  conclusion  is  reached  that  the  vein  is  so  intimately  con- 
nected with  the  base  of  the  tumor  that  it  is  in  great  danger  of  being 
injured  during  the  further  progress  of  the  extirpation,  it  becomes 
necessary  to  resort  to  direct  compression  of  the  distal  and  proximal 
portions  of  the  vein.  By  isolating  and  compressing  the  vein  on 
each  side  of  the  tumor,  both  excessive  turgidity  and  emptiness  of  the 
intervening  portion  of  the  vein  are  avoided.  The  amount  of  blood 
in  the  vein  between  the  two  points  of  compression  can  be  regulated, 
and  only  a  sufficient  quantity  allowed  to  remain  to  indicate  the  exact 
location  of  the  vessel.  Compression  is  again  made  with  haemo- 
static forceps.  After  the  complete  removal  of  the  tumor,  the 
forceps  on  the  distal  side  of  the  vein  is  removed  first,  in  order  to 
test  the  integrity  of  the  vessel  and  with  a  view  to  prevent  any  possi- 
bility of  the  entrance  of  air.  If  no  haemorrhage  takes  place  we  may 
be  satisfied  that  the  vein  has  not  been  injured,  and  the  remaining  pair 
of  forceps  can  be  safely  removed.  In  such  cases  the  exposed  portion 
of  the  vein  should  always  be  covered  with  the  adjacent  tissues  by 
deep  sutures  en  Mages  of  catgut  before  closing  the  wound. 

If  the  vein  has  been  wounded,  a  lateral  ligature  is  applied,  or 
both  ends  are  ligated  after  complete  division  of  the  vessel,  before  the 
forceps  between  the  vein  wound  and  the  heart  is  removed.  By  fol- 
lowing this  plan  we  accomplish  the  following  objects:  1.  Haemor- 
rhage from  the  injured  vein  is  slight  and  perfectly  under  the  control 
of  the  surgeon.  2.  Absolute  security  against  the  entrance  of  air. 
3.  A  more  thorough  removal  of  the  tumor. 


PROPHYLACTIC   TREATMENT   OF  AIR-EMBOLISM.  -  i  t 

3.     Ligature. 

In  all  cases  where  a  large  vein  passes  through  the  substance  of 
the  tumor  and  where  isolation  of  the  vessel  appears  inexpedient  or 
impossible,  double  ligation  recommends  itself  as  the  safest  prophy- 
lactic measure  against  both  haemorrhage  and  air- embolism.  As  soon 
as  the  base  of  the  tumor  is  reached,  the  vein  is  exposed  on  each  side 
and  tied  with  catgut,  and  the  intervening  portion  is  extirpated  with 
the  tumor.  By  adopting  this  plan  we  secure  for  the  patient  absolute 
protection  against  haemorrhage  and  air-embolism.  Adequate  col- 
lateral circulation  is  established  in  a  short  time,  so  that  ligation  or 
excision  of  the  internal  jugular  or  axillary  veins  can  be  done  under 
antiseptic  precautions  without  danger  of  causing  serious  disturbance 
of  the  cerebral  circulation  in  the  former,  or  gangrene  of  the  arm  in 
the  latter  instance.  Isolation  and  ligation  of  the  vein  on  the  proxi- 
mal side  of  the  tumor  should  always  be  resorted  to,  when  injury  to 
the  vein  is  unavoidable. 

In  case  the  prophylactic  ligation  of  the  vein  on  the  distal  side 
of  the  tumor  is  rendered  difficult  or  impossible  by  existing  circum- 
stances, the  following  course  can  be  pursued:  After  ligation  of  the 
vein  on  the  proximal  side  of  the  tumor,  a  haemostatic  forceps  is 
applied  a  little  distance  from  the  ligature  on  the  side  of  the  tumor, 
and  the  vessel  is  divided  between  the  forceps  and  the  ligature.  The 
ligature  prevents  the  entrance  of  air,  and  the  forceps  serves  the 
purpose  of  a  temporary  haemostatic  agent  during  the  extirpation  of 
the  tumor.  The  base  of  the  tumor,  with  the  vein,  is  detached  when 
the  vessel  on  the  distal  side  of  the  tumor  is  sought  for  and  tied,  and 
the  remaining  attachments  of  the  tumor,  including  the  vein,  are  cut. 
This  plan  affords  protection  against  the  entrance  of  air,  but  during 
the  separation  of  the  tumor  haemorrhage  may  occur  from  accidental 
wounds  of  the  distal  portion  of  the  vein;  which,  however,  can  be 
readily  controlled  by  compression  with  haemostatic  forceps  until  the 
vessel  is  permanently  secured  on  the  distal  side  of  the  tumor. 

4.     Aseptic  Tampon, 

It  a  large  vein  has  been  wounded,  which  from  its  location  is 
inaccessible  to  the  ligature,  permanent  compression  with  a  gradu- 
ated aseptic  tampon  will  arresi  the  haemorrhage  and  prevent  further 
ingress  of  air. 


278  EXPERIMENTAL   SURGERY. 

XVII.    Operative  Treatment  of  Air-Embolism. 

Considering  the  infrequency  of  air-embolism  as  compared  with 
the  number  of  wounds  of  the  vein,  it  is  not  surprising  to  find  that, 
as  a  rule,  surgical  writers  have  little,  if  anything,  to  say  on  the 
subject  of  the  prevention  and  treatment  of  air-embolism.  It  must 
be  apparent  to  all,  that  in  following  the  rules  laid  down  when  we 
considered  the  prophylactic  treatment,  the  accidental  introduction  of 
air  into  veins  is  prevented  almost  to  a  certainty,  and  that  they  will 
also  furnish  a  safe  guide  in  the  prevention  and  management  of 
venous  hemorrhage  when  operating  within  the  area  of  the  "  danger 
zone."  If  the  preventive  treatment  is  carefully  carried  out,  air- 
embolism  will  become  one  of  the  rarest  accidents  in  surgery. 

As  even  with  the  greatest  care  an  accident  of  this  kind  might 
happen,  it  becomes  necessary  to  allude  to  the  operative  treatment 
of  air-embolism.  The  occurrence  of  the  accident  is  sometimes 
announced  by  an  audible  hissing  or  sucking  sound,  and  is  always 
followed  almost  instantly  by  a  well-marked  train  of  distressing 
symptoms  which  are  directly  referable  to  a  mechanical  obstruction 
to  the  circulation  in  the  right  side  of  the  heart  and  the  pulmonary 
artery.  The  treatment  must  depend  on  the  quantity  of  air  which 
has  entered,  and  the  severity  of  the  symptoms  produced  by  it.  The 
therapeutic  measures  should  be  aimed  towards  meeting  the  follow- 
ing indications:  1.  Prevention  of  further  ingress  of  air.  2.  Admin- 
istration of  cardiac  stimulants  to  sustain  the  action  of  the  heart. 
3.  Venesection  to  relieve  intravenous  pressure.  4.  Aspiration  of  air 
from  the  right  side  of  the  heart  to  prevent  over-distention  and  par- 
alysis of  right  ventricle. 

I.     Prevention  of  Further  Ingress  of  Air. 

When  air  has  entered  through  a  gaping  wound  in  a  Vein  during 
inspiration,  there  is  great  danger  that  the  same  occurrence  will 
repeat  itself  during  successive  respiratory  movements  of  the  chest, 
hence  the  first  object  of  treatment  consists  in  closing  the  wound  in 
the  vein.  This  is  most  quickly  done  by  digital  compression,  which 
is  continued  until  the  vein  has  been  rendered  impermeable  by  liga- 
ture or  permanent  compression.  If  the  symptoms  are  urgent  no 
time  should  be  lost  in  securing  the  vessel  until  the  patient  has  rallied 
from  the  immediate  effects  of  the  air-embolism.     It  is  also  necessary 


OPERATIVE   TREATMENT   OF  AIR-EMBOLISM.  279 

to  postpone  the  permanent  closure  of  the  vein  until  the  time  has 
elapsed  for  any  indications  to  arise  which  would  call  for  venesection 
or  operative  removal  of  the  air  from  the  right  side  of  the  heart,  as 
in  such  cases  it  might  become  necessary  to  utilize  the  wounded  vein 
as  a  route  for  the  introduction  of  a  catheter  into  the  heart. 

When  the  time  has  arrived  for  closing  the  vein,  the  ringer  should 
not  be  removed  suddenly  from  the  vessel,  for  fear  of  causing  a  repe- 
tition of  the  accident;  it  should  remain  in  situ  until  the  vessel  can 
be  compressed  on  the  proximal  side  of  the  vein  wound  by  an  assist- 
ant. The  exact  location  of  the  wound  will  now  be  probably  indi- 
cated by  escape  of  blood  from  the  distal  end  of  the  vein,  when  the 
vessel  can  be  seized  with  a  forceps,  and  after  its  isolation,  a  double 
ligature  applied.  If  it  is  found  impossible  to  ligate  the  vein,  then 
the  vessel  is  compressed  in  the  wound  by  means  of  a  graduated 
aseptic  tampon,  retained  in  place  by  uninterrupted  pressure,  until 
definitive  closure  of  the  wound  has  taken  place. 

2.     Cardiac  Stimulation. 

The  heart's  action  must  be  supported  by  position  and  by  the 
use  of  cardiac  stimulants,  which  are  best  administered  subcutaneously 
and  by  inhalation.  The  patient  must  be  placed  in  the  horizontal 
position  in  order  to  guard  as  much  as  possible  against  the  occurrence 
of  cerebral  anaemia,  as  well  as  to  lessen  the  intravascular  pressure  to 
a  minimum.  If  the  quantity  of  air  admitted  is  not  sufficient  to 
produce  instant  death  by  paralysis  of  the  right  side  of  the  heart  in 
the  diastole,  the  symptoms  which  follow  always  point  towards  an 
embarrassment  of  the  circulation  in  the  right  side  of  the  heart  and 
the  pulmonary  artery,  which  are  always  accompanied  by  dyspnoea, 
combined  with  evidences  indicating  the  existence  of  acute  cerebral 
ischsemia. 

If  death  does  not  take  place  within  a  few  minutes  from  obstruc- 
tion to  the  circulation  through  the  pulmonary  artery  by  the  presence 
of  air  in  that  vessel,  then  the  contractions  of  the  right  ventricle  will 
force  at  least  a  part  of  the  air  through  the  pulmonary  capillaries 
into  the  general  circulation,  thus  preventing  death  by  asphyxia.  As 
soon  as  the  air-embolism  of  the  pulmonary  artery  has  been  relieved, 
the  most  urgent  symptoms  subside,  as  the  air- emboli  in  the  arterial 
system  are  distributed  over  a  larger  area  and  consequently  produce 
an  embolism  of  lesser  extent  and  gravity  in   more  distant  and   less 


280  EXPERIMENTAL  SURGERY. 

essential  organs.  The  safety  of  the  patient  depends  on  the  capacity 
of  the  right  ventricle  to  force  the  air  through  the  pulmonary  into 
the  general  circulation,  in  other  words,  upon  the  time  which  is 
required  to  remove  the  emboli  from  the  pulmonary  artery  into  the 
systemic  circulation. 

Nitrite  of  amyl,  from  its  stimulating  properties  upon  the  heart 
and  from  the  rapidity  of  its  action,  would  recommend  itself  in  the 
form  of  inhalation  as  the  most  efficient  drug  in  preventing  threatened 
syncope.  The  temporary  dilatation  of  the  small  blood-vessels  would 
tend  to  produce,  at  least  for  a  short  time,  a  diminution  of  the  intra- 
vascular pressure.  Hypodermic  injections  of  camphor  and  alcohol, 
although  slower  in  their  action,  would  also  assist  in  antagonizing 
the  deleterious  effect  of  over-distention  of  the  right  ventricle  by  the 
air-embolus.  In  all  of  my  experiments  where  electricity  was  used,  it 
had  no  effect  whatever  upon  the  heart,  even  when  applied  directly 
to  the  organ,  hence  it  would  be  of  no  use  to  resort  to  this  agent  for 
the  purpose  of  sustaining  or  re-establishing  the  movements  of  this 
organ  in  serious  cases  of  air-embolism. 

3.     Venesection. 

In  all  post-mortem  examinations  after  sudden  death  from  air- 
embolism  two  constant  pathological  conditions  are  always  found 
present:  1.  A  comparatively  empty  state  of  the  left  side  of  the  heart 
and  throughout  the  entire  arterial  system.  2.  Distention  of  the 
right  ventricle  and  intense  engorgement  of  the  whole  venous  system. 
Both  of  these  conditions  are,  of  course,  due  to  the  presence  of  air  in 
the  ultimate  branches  of  the  pulmonary  artery,  which  prevents  the 
free  transit  of  the  venous  blood  through  the  pulmonary  capillaries 
into  the  left  side  of  the  heart.  As  a  direct  result  of  these  conditions, 
we  have  a  diminution  of  the  intravascular  pressure  in  the  left  side  of 
the  heart  and  the  arteries,  and  a  corresponding  increase  in  the  right 
side  of  the  heart  and  the  veins.  The  immediate  and  greatest  danger 
arises  from  an  accumulation  of  air  and  blood  in  the  right  side  of 
the  heart,  to  such  an  extent  as  to  arrest  the  ventricular  contractions 
by  over-distention  before  the  equilibrium  between  the  arterial  and 
venous  circulation  can  be  restored  by  the  removal  of  the  air-emboli 
from  the  pulmonary  artery  into  the  general  circulation. 

Even  the  most  extreme  antagonists  to  the  lancet  must  acknowl- 
edge the  benefit  which  follows  its  use  in  similar  obstructions  .of  the 


OPERATIVE    TREATMENT   OF  AIR-EMBOLISM.  281 

circulation  caused  by  other  pathological  conditions.  In  severe  cases 
of  pneumonia  where  the  circulation  has  been  so  much  obstructed 
that  death  is  threatened  by  venous  engorgement  and  over-distention 
of  the  right  ventricle,  the  free  use  of  the  lancet  is  the  safest  and 
most  efficient  means  in  equalizing  the  circulation,  as  by  the  abstrac- 
tion of  blood  from  one  of  the  veins,  the  intravascular  pressure  in  the 
veins  and  right  side  of  the  heart  is  diminished  in  the  promptest  and 
most  direct  manner.  As  the  adventitious  air  in  the  pulmonary  capil- 
laries can  and  will  be  forced  into  the  general  circulation  by  the 
contractions  of  the  right  ventricle,  and  as  the  urgent  symptoms  will 
subside  after  this  has  taken  place,  it  is  of  paramount  importance  to 
gain  time  by  protecting  the  right  ventricle  against  an  undue  amount 
of  additional  labor. 

Among  the  indirect  remedies  to  accomplish  this  object  vene- 
section deserves  the  first  place.  I  could  refer  to  a  number  of 
the  experiments  where  copious  bleeding  from  the  distal  portion 
of  the  open  vein  was  promptly  followed  by  improvement  in  all  the 
symptoms.  Vulpian  asserted  that,  after  insufflation  of  air  into  veins, 
the  contractions  of  the  heart  were  restored  after  the  organ  had  ceased 
pulsating,  by  the  abstraction  of  blood  from  the  sinuses  of  the  brain 
and  the  veins  of  the  neck.  I  have  never  succeeded  in  restoring  the 
action  of  the  heart,  after  its  pulsations  had  ceased  completely,  by  any 
kind  of  treatment;  but,  when  the  contractions  have  become  imperfect 
from  this  cause,  I  know  that  removal  of  the  cause  of  over-distention 
will  restore  the  force  and  efficiency  of  the  contractions. 

H.  Fischer1  sarcastically  alludes  to  this  valuable  agent  in  the 
treatment  of  air-embolism  as  a  remedy  from  which  only  homoeopaths 
would  expect  to  derive  any  benefit.  An  expression  of  this  kind  con- 
cerning such  a  valuable  remedy,  and  in  this  particular  connection, 
must  be  looked  upon  as  unscientific  and  contrary  to  well-established 
clinical  and  pathological  facts.  I  must,  therefore,  insist  that  vene 
section  from  the  distal  end  of  the  wounded  vein  will  prove  beneficial 
in  all  cases  of  air-embolism  where  venous  engorgement  and  over- 
distention  of  the  right  ventricle  constitute  elements  of  imminent 
danger.  If  practicable,  the  bleeding  should  always  be  done  from 
the  distal  end  of  the  wounded  vein,  while  the  proximal  end  is  com- 
pressed or  ri gated.     The  advantages  of  doing  so  are  obvious  for  the 

1  Ueber  die  Gefahren  des  Lufteintritts  in  die  Venen,  p.  17. 


282  EXPERIMENTAL  SURGERY. 

following  reasons:  1.  The  abstraction  of  blood  is  accomplished  in 
the  shortest  possible  space  of  time.  2.  The  blood  escapes  in  a  large 
stream  from  a  capacious  vessel.  3.  No  additional  instruments  are 
required,  and  the  infliction  of  another  wound  is  obviated. 

4.     Aspiration  of  Air  from  the  Heart. 

Clinical  experience  and  experimental  research  teach  us  that 
when  a  certain  amount  of  air  enters  the  right  side  of  the  heart,  death 
invariably  takes  place  in  a  very  short  time  and  cannot  be  prevented 
by  any  of  the  indirect  methods  of  treatment.  It  seems  to  me  that 
in  such  cases  it  would  be  legitimate  and  proper  for  the  surgeon  to 
resort  to  some  procedure  by  which  the  air  could  be  removed  directly 
from  the  heart.  To  accomplish  this  object  Fischer  recommends  that 
forcible  expiratory  movements  should  be  excited  by  inducing  cough- 
ing, sneezing,  or  vomiting,  with  a  view  that  during  the  forcible 
compression  of  the  thorax  the  aspirated  air  would  be  forced  out 
through  the  wound  in  the  vein.  Against  this  advice  the  following 
objections  may  be  entered: 

1.  The  difficulty  or  impossibility  of  exciting  coughing,  sneez- 
ing, vomiting,  or  any  other  act  on  the  part  of  the  patient  when  in  a 
condition  of  collapse. 

2.  If  during  the  forcible  compression  of  the  chest,  the  air  is 
forced  backwards,  it  will  be  just  as  likely  to  pass  into  other  veins 
than  the  one  through  which  it  entered. 

3.  The  difficulty  of  preventing  the  admission  of  more  air 
during  the  forcible  inspiration  following  the  forcible  expiration. 

4.  During  prolonged  forcible  expiration  the  intravascular 
pressure  in  the  veins  and  right  side  of  the  heart  is  greatly  increased, 
thus  constituting  an  additional  source  of  immediate  danger. 

5.  Forcible  expiratory  movements  of  the  thorax,  by  compress- 
ing the  .heart,  will  be  more  likely  to  force  the  air  onward  with  the 
venous  current  into  the  pulmonary  artery,  where'  it  will  do  the  most 
harm  by  causing  asphyxia  from  a  sudden  and  extensive  air-embolism 
in  that  vessel. 

The  only  direct  means  of  removing  air  from  'the  heart  consist 
in  puncture  of  the  right  ventricle  and  catheterization  of  the  right 
auricle  combined  with  aspiration.  The  experiments  made  by  myself 
in  this  direction  have  demonstrated  that  puncture  of  the  right 
ventricle  with  an  aseptic  needle  two  millimeters  in  diameter  is  in 


OPERATIVE    TREATMENT    OF  AIR-EMBOLISM.  283 

itself  a  harmless  procedure.  When  we  remember  that  in  the  human 
subject  the  heart  has  often  been  the  seat  of  more  extensive  injury 
without  any  immediate  or  remote  ill  effects,  we  must  abandon  the 
idea  that  slight  injuries  of  this  organ  are  necessarily  fatal.  Small 
aseptic  wounds  of  the  heart  heal  rapidly,  and  in  the  same  manner 
as  in  any  other  organ  of  the  body. 

In  the  preceding  experiments  the  hearts  were  removed  from 
dogs  a  few  days  to  three  weeks  after  puncture;  and  not  in  a  single 
specimen  are  we  able  to  detect  any  evidences  of  organic  changes, 
either  in  the  substance  of  the  organ  or  its  serous  membranes.  In 
most  of  the  specimens  the  point  of  puncture  was  marked  by  a 
minute  cicatrix,  visible  upon  the  surface  of  the  visceral  pericardium. 
In  penetrating  wounds  of  the  heart,  haemorrhage  into  the  pericardium 
and  compression  of  the  heart  from  this  cause  are  to  be  feared,  and 
constitute  the  only  source  of  immediate  danger.  There  is  no 
plausible  reason  why  in  the  human  subject  an  oblique  puncture  of 
the  right  ventricle  should  be  followed  by  more  haemorrhage  than  in 
animals,  and  consequently  I  have  no  hesitation  in  recommending 
puncture  and  aspiration  of  the  heart  as  a  justifiable  procedure  in 
cases  of  air-embolism  which  would  otherwise  necessarily  prove  fatal. 

The  question  naturally  arises :  What  symptoms  indicate  a  resort 
to  puncture  and  aspiration  of  the  right  ventricle?  Two  different 
conditions,  as  far  as  time  and  symptoms  are  concerned,  may  call  for 
this  operation.  The  puncture  should  be  made  as  soon  as  possible 
after  the  entrance  of  air,  in  the  event  that  the  primary  effect  of  the 
heart  embolus  has  produced  sudden  over- distention  and  paralysis  of 
the  right  ventricle,  an  occurrence  which  would  be  indicated  by 
immediate  collapse  and  partial  or  complete  suspension  of  the  heart's 
action.  In  such  a  case  the  direct  withdrawal  of  air  from  the  right 
ventricle,  as  soon  as  possible  after  its  entrance,  affords  the  only 
possible  hope  of  restoring  the  pulsations  of  the  heart,  by  removing 
the  cause  of  the  mechanical  over-distention. 

In  the  second  class  of  cases  the  patient  has  collapsed,  but  the 
heart  has  withstood  the  primary  effect  of  the  aspirated  air.  The 
heart's  action  is  rapid  and  tumultuous,  perhaps  at  times  intermittent. 
The  ear  applied  over  the  cardiac  region  detects  distinct  churning 
sounds.  Respirations  are  rapid,  and  all  symptoms  point  towards 
imperfect  circulation  and  aeration  of  the  blood  as  expressed  by  the 
pallid  face  and  blue  lips.     Some  of  the  air  has  passed   from  the 


284  EXPERIMENTAL  SURGERY. 

right  side  of  the  heart  into  the  pulmonary  artery,  and  from  the 
obstruction  of  the  circulation  through  this  vessel,  the  right  ventricle 
becomes  more  and  more  distended,  the  contractions  therefore 
becoming  less  perfect  and  more  frequent.  At  this  stage,  puncture 
and  aspiration  of  the  right  ventricle  will  overcome  the  most  urgent 
symptoms  by  the  removal  of  air  and  spumous  blood,  and  enough 
time  may  be  gained  for  the  right  ventricle  to  force  the  remaining 
air- emboli  through  the  pulmonary  capillaries  into  the  general 
circulation,  and  the  life  of  the  patient  is  saved. 

These  are  the  cases  where  puncture  and  aspiration  of  the  right 
ventricle  can  be  done  with  a  fair  prospect  of  not  only  relieving 
urgent  symptoms,  but  of  ultimate  recovery.  They  are  also  more 
favorable  from  the  fact  that  more  time  is  afforded  the  surgeon  in 
procuring  and  using  the  aspirator.  The  puncture  should  always  be 
made  in  an  oblique  direction,  from  below  upwards,  so  as  to  make  a 
valvular  tract  in  the  heart  for  the  purpose  of  preventing  haemorrhage 
into  the  pericardium,  and  also  for  giving  the  point  of  the  needle  a 
direction  in  which  it  is  least  likely  to  injure  the  opposite  endocardial 
lining.  The  left  intercostal  space,  between  the  fourth  and  fifth  ribs, 
about  an  inch  and  one-half  from  the  margin  of  the  sternum,  is 
selected  as  the  best  point  for  making  the  puncture.  The  needle, 
thoroughly  disinfected,  is  connected  with  the  aspirator,  and,  as  soon 
as  its  point  is  buried  in  the  tissues,  a  vacuum  is  created  in  the 
aspirator,  and  the  needle  is  advanced  slowly  until  spumous  blood  is 
felt  and  seen  to  escape,  when  it  is  firmly  held  in  this  position,  and 
the  contents  of  the  ventricle  are  withdrawn  as  quickly  as  possible. 
My  experiments  have  satisfied  me  that  I  generally  removed  the 
needle  too  soon,  not  having  withdrawn  a  sufficient  quantity  of  blood 
and  air.  In  some  of  the  experiments  I  followed  the  aspiration  by 
blood-letting  with  marked  benefit.  Removal  of  the  same  quantity 
of  blood  directly  from  the  right  ventricle  would  have  been  produc- 
tive of  more  good,  as  less  air  would  have  been  left  in  the  heart. 

The  experiments  on  dogs  have  shown  that  these  animals  will 
always  recover  if  the  quantity  of  air  injected  into  the  veins  does  not 
exceed  one  c.  cm.  of  air  to  each  pound  of  its  weight.  Double  this 
quantity  must  be  considered  a  fatal  dose.  If,  therefore,  we  can 
remove  by  aspiration  only  a  portion  of  air  directly  from  the  right 
ventricle,  we  may  be  able  to  maintain  the  action  of  the  heart  and 
respiration  until   the  embolism  of  the  pulmonary  artery  has.  been 


OPERATIVE    TREATMENT    OF  AIR-EMBOLISM.  285 

relieved  by  the  passage  of  air  from  this  vessel  into  the  general  cir- 
culation. When  the  presence  of  a  foreign  body  in  any  other  part  of 
the  body  threatens  to  destroy  life,  no  surgeon  would  hesitate  to  make 
an  attempt  to  remove  it,  even  if  the  effort  should  be  attended  by  an 
increase  of  the  immediate  risk. 

Air  in  the  right  side  of  the  heart  acts  the  part  of  a  foreign 
body,  and,  when  it  destroys  life,  it  does  so  by  causing  mechanical 
obstruction  to  the  circulation.  The  timely  removal  of  the  air  is  the 
only  rational  treatment  in  all  cases  where  simpler  measures  have 
proved  inadequate  in  preventing  a  fatal  termination.  An  aspirator 
in  good  condition  should  be  on  hand  in  every  well  regulated  hospital, 
and  of  ready  access  in  cases  of  emergency.  If  air-embolism  occurs 
during  an  operation,  the  instrument  should  be  used  before  the  heart 
has  ceased  pulsating,  when  prompt  action  on  the  part  of  the  operator 
may  obviate  death  in  an  otherwise  hopeless  case. 

The  experiments  on  catheterization  of  the  heart  were  undertaken 
with  a  view  to  simplify  the  operative  removal  of  air  from  the  right  side 
of  the  heart.  An  aseptic  catheter  was  introduced  into  the  wounded 
vein  and  passed  into  the  right  auricle,  and  by  aspiration  air  and 
spumous  blood  were  removed.  The  result  showed  that  some  of  the 
animals  were  saved  from  impending  death  by  this  simple  procedure. 
The  great  danger  attending  this  operation  consisted  in  the  tendency 
of  the  blood  to  coagulate  within  or  around  the  distal  end  of  the 
catheter,  and  death  from  the  formation  of  a  thrombus  in  the  large 
veins  and  right  side  of  the  heart.  If  the  formation  of  a  thrombus 
could  in  some  way  be  prevented  with  certainty,  catheterization  and 
aspiration  of  the  heart  would  recommend  itself  as  the  simplest  and 
safest  measure  in  the  operative  treatment  of  air-embolism. 

Catheterization  of  the  heart  is  not  a  new  suggestion,  as  the 
introduction  of  a  tube  into  the  heart  for  the  same  purpose  was 
recommended  more  than  fifty  years  ago  by  Magendie.  I  should 
recommend  the  adoption  of  this  procedure  only  when  the  air  has 
entered  through  a  wound  in  the  internal  jugular,  and  when  the 
symptoms  leave  no  doubt  that  death  would  be  inevitable  without 
direct  removal  of  the  air  by  aspiration.  An  aseptic  Nelaton's  catheter 
with  an  open  end  should  be  introduced  into  the  wound  through  which 
the  air  entered,  and  pushed  as  quickly  as  possible  as  far  as  the 
auricle,  when  the  air  and  spumous  blood  can  be  withdrawn  by  the 


286  EXPERIMENTAL   SURGERY. 

mouth  in  the  absence  of  any  other  means  of  aspiration.  Admission 
of  more  air  is  prevented  by  compression  of  the  distal  end  of  the 
instrument  before  and  between  the  aspirations.  The  whole  opera- 
tion must  be  done  as  quickly  as  possible  for  the  purpose  of  prevent- 
ing coagulation  of  the  blood.  For  the  same  reason  an  instrument 
of  large  calibre  should  be  used. 

In  presenting  the  practical  outcome  of  my  experimental  work 
in  the  foi-m  of  these  few  suggestions  on  the  operative  treatment  of 
air-embolism,  I  am  fully  aware  that  it  may  be  said  that  my  labor  has 
been  in  vain,  and  that  the  means  suggested  do  not  admit  of  applica- 
tion in  practice.  In  reply,  I  will  say  that  desperate  cases  call  for 
desperate  measures.  When  death  stares  us  in  the  face  we  have  not 
only  a  right,  but  it  becomes  our  most  imperative  duty  to  resort  to 
any  plan  of  treatment  which  holds  out  the  slightest  hope  of  saving 
the  life  of  the  patient. 

For  myself  I  am  fully  convinced  of  the  safety  and  usefulness 
of  puncture  and  aspiration  of  the  right  ventricle  in  grave  cases  of 
air-embolism,  where  simpler  means  have  proved  of  no  avail.  When 
no  aspirator  is  within  reach,  I  also  believe  in  the  propriety  of 
catheterization  and  aspiration  of  the  heart  as  a  last  resort  in  all 
cases  of  air-embolism  where  death  would  surely  take  place  without 
it.  If  by  the  adoption  of  either  of  these  methods  of  direct  treat- 
ment of  air-embolism  a  single  human  life  should  be  saved,  I  shall 
feel  amply  rewarded  for  the  labor  incurred  in  the  preparation  of  this 
paper. 

XTIII.     Summary. 

1.  The  presence  of  adventitious  air  in  the  vascular  system 
during  life  gives  rise  to  air -embolism. 

2.  Each  air- embolus  constitutes  a  mechanical  source  of  partial 
or  complete  obstruction  to  the  flow  of  blood  in  the  vessel  in  which  it 
is  located. 

3.  Aspiration  during  the  inspiratory  movements  of  the  chest 
is  the  direct  or  exciting  cause  of  ingress  of  air  into  a  wounded  vein 
or  sinus. 

4.  Elevation  of  the  head  is  the  sole  predisposing  cause  of  the 
entrance  of  air  in  wounds  of  the  superior  longitudinal  sinus. 


SUMMAEY.  287 

5.  In  veins  the  predisposing  causes  consist  in: 

a.  Elevation  of  the  part  wounded. 

b.  Pathological    or    anatomical   conditions  which    prevent 

collapse  of  the  vein  when  it  is  wounded. 

6.  Insufflation  of  a  fatal  quantity  of  air  into  a  vein  produces 
death  by : 

a.  Mechanical  over-distention  of  the  right  ventricle  of  the 

heart,  and  paralysis  in  the  diastole. 

b.  Asphyxia  from  obstruction  to  the  pulmonary  circulation 

consequent  upon  embolism  of  the  pulmonary  artery. 

7.  Insufflation  of  a  quantity  of  air  into  the  arteries  is  less 
dangerous  than  when  the  same  quantity  is  introduced  into  veins. 
When  death  is  produced  in  this  manner  it  results  from: 

a.  Acute  cerebral  ischaemia. 

b.  Secondary  venous  air-embolism. 

c.  Intense  collateral    engorgement  of   the  vessels  of   the 

brain  and  spinal  cord. 
The  manner  of   death  is  determined  by   the  amount   of    air 
injected,  and  the  direction  in  which  the  injection  is  thrown,  as  well 
as  by  the  time  which  has   elapsed  between  the  operation  and  the 
fatal  termination. 

8.  Air  injected  into  arteries  is  readily  forced  through  the 
systemic  capillaries  into  the  venous  circulation  and  right  side  of 
the  heart  by  the  powerful  contractions  of  the  left  ventricle. 

9.  Air-embolism  of  the  pulmonary  artery  is  relieved  in  a  com- 
paratively short  time,  provided  the  contractions  of  the  right 
ventricle  continue  unimpaired  for  a  sufficient  length  of  time  to  force 
the  air  through  the  pulmonary  capillaries  into  the  general  cir- 
culation. 

10.  The  prophylactic  treatment  consists  in  proximal  or  double 
compression  or  ligation  of  the  vein  which  is  endangered  by  the 
operation. 

1 1.  The  indirect  treatment  has  for  its  objects: 

a.  Prevention  of  admission  of  air. 

b.  Administration  by  inhalation  or  hypodermic  injection  of 

cardiac  stimulants. 

c.  Venesection. 


288  EXPERIMENTAL   SURGERY. 

12.  The  direct  or  operative  treatment  by: 

a.  Puncture  and  aspiration  of  the  right  ventricle. 

b.  Catheterization   and    aspiration   of    the   right   auricle, 

which  are  proposed  with  a  view  to  obviate  the  direct 
cause  of  death  by  the  removal  of  air  and  spumous 
blood,  thus  relieving  directly  the  over-distention  of 
the  right  ventricle,  and,  at  the  same  time,  to  guard 
against  a  fatal  embolism  of  the  pulmonary  artery. 

13.  The  results  obtained  by  experiments  on  animals  warrant 
the  adoption  of  the  operative  treatment  of  air-embolism  in  practice, 
as  a  last  resort,  in  all  cases  where  the  indirect  treatment  has  proved 
inadequate  to  meet  the  urgent  indications. 


THE  SURGERY  OF  THE  PANCREAS,  AS  BASED  UPON 
EXPERIMENTS  AND  CLINICAL  RESEARCHES.1 


In  the  following  article,  an  attempt  will  be  made  to  lay  the 
foundations  for  a  rational  method  of  treatment  of  some  of  the 
injuries  and  diseases  of  the  pancreas  by  direct  surgical  measures. 
The  literature  on  the  surgery  of  the  pancreas  is  exceedingly  scanty 
and  loosely  scattered  through  the  medical  journals  and  text-books, 
as  no  previous  attempt  has  been  made  to  arrange  the  material  in  a 
systematic  form  for  ready  reference.  Our  present  knowledge  of  the 
surgical  treatment  of  diseases  of  the  pancreas  is  limited  to  a  few 
operations  performed  for  the  cure  of  retention  cysts,  by  excision  or 
the  formation  of  an  external  pancreatic  fistula.  The  clinical  mate- 
rial which  I  have  collected,  and  more  particularly  the  description  of 
pathological  conditions  found  within  and  around  the  pancreas  at 
post-mortem  examinations,  will  be  utilized  for  the  purpose  of  point- 
ing out  new  indications  for  operative  interference,  by  such  methods 
as  will  suggest  themselves  from  the  results  obtained  by  experiments 
upon  animals. 

I.    Comparative  Anatomy  of  the  Pancreas. 

A  few  words  on  the  comparative  anatomy  of  the  pancreas  are 
necessary  in  order  to  compare  the  results  obtained  by  certain  experi- 
ment with  similar  conditions  when  observed  in  the  human  subject 
as  the  result  of  traumatism  or  pathological  changes.  In  some  of 
the  higher  invertebrates  certain  organs  connected  with  the  alimentary 
canal  have  received  the  name  of  pancreas;  but  they  have  done  so 
rather  from  their  position  and  inferred  function  than  from  any  cer- 
tain evidence  of  their  use,  or  from  their  anatomical  structure.2  If 
they  exist,  they  consist  of  simple  CSecal  appendages  attached  to  the 
upper  part  of  the  intestine. 

1  Read  before  the  American  Surgical  AB8ociation,  1886. 

2  Cyclopaedia  of  Anatomy  and  Surgery,  vol.  v.  p.  DO. 

19  .  289 


290  EXPERIMENTAL   SURGERY. 

In  the  osseous  fishes,  certain  caeca  or  blind  tubes  may  be  seen 
at  the  commencement  of  the  intestinal  canal,  close  to  the  pylorus, 
which  from  their  position  have  received  the  name  of  pyloric  append- 
ages, and  have  been  regarded  by  most  anatomists  as  the  analogue  of 
the  pancreas  in  higher  animals.  In  reptiles,  we  make  a  greater 
approach  to  the  structure  of  the  pancreas  of  higher  animals,  both  in 
form  and  structure.  In  the  frog  the  pancreas  is  shaped  not  unlike 
that  of  the  human  subject,  but  its  broad  end  is  in  the  opposite  direc- 
tion. It  is  in  close  approximation  with  the  duodenum  in  its  whole 
length.  A  proper  duct  cannot  be  found;  probably  small  ducts  from 
different  parts  of  the  gland  open  into  the  biliary  duct  as  it  passes 
through  the  gland.  The  pancreas  of  birds  is  proportionately  larger 
than  in  any  other  animal.  The  gland  has  always  more  than  one, 
usually  two  or  three  ducts,  which  open  by  separate  orifices  and  often 
at  some  considerable  distance  from  one  another. 

The  chief  differences  between  the  pancreas  in  other  mammalia 
and  in  man  relate  merely  to  its  color,  its  consistence,  its  degree  of 
lobulation,  its  form,  its  volume,  its  union  into  a  single  mass  or  its 
separation  into  two  distinct  parts,  and,  lastly,  its  position  and  rela- 
tions with  different  portions  of  the  peritoneum. 

Its  form  is  generally  more  or  less  that  of  a  narrow  band,  divisible 
into  two  portions:  one,  the  duodenal,  following  the  curvature  of  the 
duodenum,  and  placed  vertically  or  obliquely;  the  other,  the  gastro- 
splenic,  extending  transversely,  and  therefore  opposite  the  other, 
from  the  duodenum  to  the  spleen,  against  which  it  rests;  the  latter 
is  always  developed,  the  former  is  often  defective  or  absent,  and 
must  be  considered  merely  as  an  accessory  portion. 

In  the  carnivora  the  pancreas  is  always  large  in  proportion  to 
the  size  of  the  animal.  In  the  ox,  from  the  distinctness  of  the  two 
portions,  the  organ  has  a  bilobar  appearance.  In  the  horse,  from  the 
gastrosplenic  portion  being  doubled,  it  has  a  trilobar  form.  In  the 
rodents,  the  organ  is  spread  out  in  an  arborescent  manner  in  an 
extensive  mesentery  that  imparts  free  movement  to  the  long  duode- 
num, and  extends  to  the  left  in  a  sort  of  omentum  which  underlies 
the  stomach.  In  the  rabbit,  the  duct  enters  the  intestine  nine  inches 
or  a  foot  from  the  pylorus. 

In  the  mammalia,  as  in  man,  there  is  usually  but  one  pancre- 
atic duct,  which  enters  the  intestine  near  the  pylorus,  although  some- 
times a  great  way  removed  from  it.     There  are,  however,  considerable 


COMPARATIVE  ANATOMY   OF   THE   PANCREAS.  291 

varieties  of  insertion.  In  the  lion,  two  pancreatic  ducts  join  the 
common  bile-duct  separately,  one  near  the  other.  In  the  dog,  I  have 
made  the  observation  that  the  ducts  from  both  portions  of  the  pan- 
creas unite  near  the  duodenum  or  within  its  wall,  and  that  the  orifice 
of  the  common  pancreatic  duct  is  usually  located  about  an  inch  or  two 
below  the  opening  of  the  bile-duct.  If  an  accessory  duct  exists,  it 
usually  opens  into  the  intestine  at  a  point  in  common  with  the 
bile-duct. 

Berard  and  Colin1  have  shown  that  the  pancreas  is  not  connected 
with  the  duodenum  in  young  dogs.  It  consists  originally  of  two 
parts,  of  which  one  lies  parallel  to  the  duodenum  (caudex  inferior), 
and  the  other  perpendicular  (caudex  superior).  These  two  portions 
join  later  to  form  a  mass  which  becomes  adherent  to  the  duodenum. 
Each  portion  has  its  own  duct,  which  afterward  join  to  enter  the 
intestine  about  two  and  a  half  centimeters  below  the  opening  of  the 
bile-duct.  Sometimes  there  is  a  second  duct  arising  from  either 
portion,  or  more  rarely  from  both,  which  enters  the  duodenum  by  the 
side  of  the  bile-duct. 

The  pancreas  of  the  pig  has  usually  only  one  duct,  but  when 
two  exist,  the  second  smaller  duct  communicates  with  the  principal 
duct,  which  opens  into  the  common  bile-duct. 

The  irregular  distribution  and  insertion  of  the  pancreatic  duct 
in  mammalia  and  the  frequency  with  which  a  second  and  third  duct  is 
found,  are  important  to  remember  in  connection  with  experiments 
on  the  pancreas,  by  intercepting  the  secretion  by  ligation  of  the  duct; 
as  it  is  exceedingly  difficult  if  not  impossible  to  ascertain  the  exist- 
ence or  absence  of  the  small  accessory  ducts,  and  on  this  account  it 
would  be  impossible  to  prove  that  all  of  the  outlets  of  the  gland  had 
been  intercepted,  even  if  more  than  one  duct  had  been  found  and 
ligated. 

II.     Development  of  the  Pancreas. 

Remak2  has  studied  the  development  of  the  pancreas  in  the 
young  chick.  He  found  that  the  matrix  could  be  seen  somewhat 
later  than  that  of  the  liver — about  sixty-five  hours  after  incubation 
had  commenced.     It  consists  primarily  of  a  bulging  of  the  hypoblast 

1  Canstatt's  Jahresbericht,  1857,  1-3,  p.  64. 

2  Entwickelung  der  Wirbelthiere,  Berlin,  1855,  pp.  54,  115,  1<>4. 


292 


EXPERIMENTAL  SURGERY. 


of  the  posterior  wall  of  the  intestinal  tube,  covered  by  a  thickened 
prolongation  of  the  connective  tissue  layer  of  the  bowel.      (Fig.  1). 

The  embryonal  pancreas  shows  in  the  beginning  a  cavity  which 
is  in  communication  with  the  open  lumen  of  the  bowel.  The 
changes  which  take  place  in  the  embryonal  pancreas  during  the  first 
five  days  can  be  readily  observed  and  are  easily  understood. 

From  the  thick  wall  of  the  hypoblast,  numerous  small,  solid 
lobules  spring,  while  the  hollow  space  in  communication  with  the 
bowel  assumes  more  and  more  the  shape  of  a  canal.  The  connective 
tissue  layer  does  not  increase  in  size  in  the  same  degree,  and  pre- 
sents no  lobular  projections  upon  its  surface.     On  this  account  the 


Fig.  1.     Embryo  of  chick,  four  days  old. 

a.  Stomach. 

b.  Liver  and  bile-ducts. 

c.  Pancreas. 


new  organ  has  assumed  a  pyriform  shape  externally;  on  the  other 
hand,  the  glandular  portion  in  the  connective  tissue  layer  takes  on  a 
branched  structure.     (Fig.  2.) 

The  hypoblastic  layer  is  the  basis  of  the  parenchyma.  Com- 
posed of  cells,  the  connective  tissue  layer  serves  as  the  basis  for  the 
vascular  constituents  of  the  gland.  The  embryonal  connective 
tissue  disappears  during  the  development  of  the  gland  in  proportion 
as  the  cellular  portion  increases,  until,  finally,  only  enough  connective 
tissue  is  left  to  serve  as  a  nidus  for  the  vessels  and  as  a  membrana 
propria  of  the  acini. 


COMPARATIVE   ANATOMY   OF  THE   PANCREAS.  293 


a 


Fig.  2.     Embryo  of  chick,  five  days  old. 


•  i.  Stomach. 

b.    Liver  and  bile-duct. 


c.  Gall-bladder. 

d.  Pancreas. 


294  EXPERIMENTAL  SURGERY. 

The  pancreas  is  not  developed  by  symmetrical  folding  of  both 
walls  of  the  intestinal  canal,  but  each  wall  grows  by  proliferation  in 
different  degrees  to  form  the  pancreas.  The  excavation  in  the  rudi- 
mentary gland  does  not  exist  at  first,  but  the  original  and  essential 
structures  are  the  cellular  parenchyma  of  the  gland  from  the 
epithelial  lining  of  the  intestine,  and  the  vessel-  and  nerve- envelop- 
ing layer  of  connective  tissue.  As  the  pancreas  in  birds  has  two 
ducts,  the  question  arose  how  the  second  duct  was  formed.  The  most 
plausible  explanation  was  afforded  by  the  assumption  that  the 
primary  dtict  divides  itself  into  two  in  a  longitudinal  direction. 

Remak,  in  1846,  found  another  explanation  by  examining  two 
geese,  between  three  and  four  weeks  old.     He  found  two  ducts  at  a 


Fig.  3.     Larva  of  frog. 

a.  Pancreas. 

b.  Pancreatic  duct. 

short  distance  from  each  other,  in  connection  with  the  wall  of  the 
intestine.  A  closer  examination  showed,  however,  that  only  one  of 
the  ducts,  the  upper,  was  in  communication  with  the  lumen  of  the 
intestine;  the  other  presented  a  blind  pouch  adherent  to  the  wall  of 
the  intestine. 

From  this,  it  may  be  concluded  that  the  second  duct  springs 
from  the  first,  and,  at  a  later  period,  a  new  communication  with 
the  bowel  is  established  at  a  point  corresponding  to  its  c?ecal 
extremity.  He  has  since  observed  the  same  condition  in  the  larva? 
of  frogs.     (Fig.  3.) 

It  appears  then  established  that  the  first  and  primary  duct  of 


PHYSIOLOGY   OF   THE   PANCREAS.  295 

the  pancreas  is  found  in  the  rudimentary  organ,  and  is  from  the 
beginning  in  communication  with  the  bowel;  while  any  additional 
ducts,  whether  normal  or  anomalous,  originate  in  the  substance  of 
the  gland  and  are  only  secondarily  brought  in  communication  with 
the  bowel  by  a  process  of  atrophy  and  absorption  between  the  c?ecal 
extremity  of  the  duct  and  the  intestinal  wall.  The  existence  of 
anomalous  ducts  communicating  with  one  of  the  principal  ducts  and 
the  intestine  can  be  explained  in  a  similar  manner.  Thus,  in  dogs, 
it  is  uncommon  to  rind  a  small  duct  in  the  gastrosplenic  half  of  the 
gland,  connecting  the  intestine  at  a  point  where  the  common  bile- 
duct  opens  into  the  intestine,  with  the  common  duct,  as  illustrated 
in  figure  17. 

It  is  apparent  that  in  cases  of  this  kind  obliteration  of  the 
common  duct  on  the  distal  side  of  the  anomalous  or  accessory  duct 
would  not  interfere  with  the  normal  evacuation  of  the  secretion  into 
the  intestinal  canal.  The  occurrence  of  an  accessory  pancreas  can 
only  be  explained  by  the  assumption  that  during  the  growth  of  the 
rudimentary  pancreas,  certain  portions  of  the  secreting  structure 
become  isolated  by  constriction  and  displacement,  and  that  such 
portions  of  the  gland  are  brought  into  communication  with  the 
intestinal  canal  by  the  development  of  an  accessory  duct. 

III.     Physiology  of  the  Pancreas. 

A  brief  consideration  of  the  most  important  functions  of  the 
pancreas  becomes  necessary  in  connection  with  our  subject,  as  it 
will  serve  to  furnish  an  interpretation  of  some  of  the  symptoms 
observed  in  such  affections  of  the  pancreas  as  interfere  with  the 
normal  secretion  or  outflow  of  the  pancreatic  juice. 

Claude  Bernard,  in  1848,  discovered  the  most  important 
function  of  the  pancreatic  juice,  by  observing  that  it  exerted  an 
emulsifying  effect  upon  all  kinds  of  fat.  He  found  that  by  mixing 
fresh  pancreatic  juice  with  oil.  lard,  butter,  or  tallow,  and  keeping 
the  mixture  at  a  temperature  of  35°  to  40°  C,  an  emulsion  formed 
almost  immediately.1  Saliva,  gastric  juice,  bile,  and  blood-serum  do 
not  produce  this  effect.  The  emulsifying  process  takes  place  by  the 
division  of  fat  into  minute  globules  by  the  pancreatic  juice,  without 
converting  it  into  a  new  chemical  compound.     The  organic  principle 

1  Bchleiden  and  Proriep's  Neue  Notizen,  vol.  vii..  No.  L36,  pp.  •"'•"'■  56. 


296  EXPERIMENTAL   SURGERY. 

in  the  juice  which  possesses  this  property  is  very  easily  decomposed 
and  precipitated  by  heat.  Bile,  with  pancreatic  juice,  dissolves 
neutral  as  well  as  acid  fats. 

Bernard  ligated  both  pancreatic  ducts  in  dogs,  and  the  single 
duct  in  rabbits,  and  fed  the  animals  on  fat.  The  fat  was  found 
unchanged  in  the  intestinal  canal  and  the  lacteals  were  empty. 
Fatty  diarrhoea  has  been  observed  in  a  number  of  cases  where  the 
pancreas  was  the  seat  of  extensive  lesions,  and  the  presence  of  this 
symptom  should  always  lead  the  physician  to  make  special  search 
for  additional  symptoms  confirming  the  suspicion  of  the  existence  of 
disease  of  the  pancreas. 

There  is  no  dispute  among  physiologists  in  regard  to  the 
action  of  pancreatic  juice  in  transforming  starch  into  sugar.  This 
function  was  first  observed  by  Valentin,  in  1844,  who  experimented 
with  an  artificial  fluid  made  by  infusing  pieces  of  pancreas  in  water. 
Bouchardat  and  Sankras  first  observed  this  property  in  the  normal 
pancreatic  secretion.  The  property  of  converting  starch  into  sugar 
is  possessed  also  by  the  saliva  and  intestinal  juice;  it  therefore 
becomes  an  important  question  to  determine  the  effect  of  a  defective 
pancreatic  secretion  in  cases  where  there  is  imperfect  digestion  of 
starchy  food.  It  seems  that  cane  sugar  is  transformed  into  glucose 
almost  exclusively  by  the  action  of  the  pancreatic  juice. 

This  fact  has  received  confirmation  in  the  case  of  intestinal 
fistula  observed  by  Busch.  The  fistula  was  located  in  the  lower 
portion  of  the  small  intestine.  When  cane  sugar  was  introduced  in 
quantity  into  the  stomach,  fasting,  the  fluid  which  escaped  from  the 
upper  end  of  the  intestine  contained  a  small  quantity  of  glucose,  but 
never  any  cane  sugar.  Cane  sugar  introduced  into  the  fistula  so 
that  it  would  pass  along  only  the  lower  end  of  the  bowel,  was  not 
converted  into  glucose,  but  a  large  portion  of  it  was  found  in  the 
fasces  as  cane  sugar.  In  cases  of  suspected  organic  lesions  of  the 
pancreas  it  would,  therefore,  appear  advisable  to  resort  to  feeding 
with  cane  sugar  and  subsequent  examination  of  the  stools  for  undi- 
gested cane  sugar,  as  a  diagnostic  measure.  The  presence  of  cane 
sugar  in  the  stools  would  indicate  that  little  or  no  pancreatic  juice 
was  being  secreted. 

The  last  function  of  the  pancreas  consists  in  converting,  with 
the  aid  of  the  bile  and  intestiual  juice,  the  albuminoids,  such  as 
gluten,  fibrin,  albumen,  casein,  and  musculine  into  albuminose  or 


PHYSIOLOGY   OF   THE   PANCREAS.  291 

peptones.  This  latter  effect  of  the  pancreas  has  been  doubted  by  a 
number  of  German  physiologists,  but  the  fact  seems  to  be  demon- 
strated by  experiment  as  well  as  by  the  circumstance  that  the 
pancreas  is  larger  in  carnivorous  than  in  herbivorous  animals. 

Schiff  has  found  that  the  physiological  function  of  the  pancreas 
is  at  its  maximum  about  nine  hours  after  the  ingestion  of  food,  and 
at  its  minimum  about  four  to  six  hours  later.  During  the  greatest 
activity  of  the  gland  the  vessels  become  more  turgid,  and  can  be 
seen  with  the  aid  of  a  lens  between  and  upon  the  lobules,  while 
during  a  state  of  rest  they  are  seen  only  between  the  lobules. 
During  digestion  the  gland  presents  a  pale  red  color,  while  during 
rest  it  appears  grayish-white. 

The  influence  of  the  nerve-centers  upon  the  pancreas  has  been 
made  a  subject  of  careful  study  by  Schiff.1  Section  of  both  pneumo- 
gastric  nerves  has  no  effect  upon  the  circulation  or  secretion  of  the 
pancreas.  Animals  subjected  to  this  experiment  readily  digested 
dextrine  or  peptones  introduced  into  the  stomach;  but  if  ordinary 
food  was  given,  no  secretion  took  place,  as  stomach  digestion  was 
suspended.  Total  destruction  of  the  three  semilunar  ganglia  of  the 
sympathetic  arrests  completely  the  secretory  functions  of  the  pan- 
creas, even  if  the  most  favorable  conditions  are  established  by  the 
introduction  of  food  or  injection  of  the  products  of  digestion  into 
the  stomach.  Wounding  of  these  ganglia,  short  of  total  destruction, 
does  not  produce  the  same  effect. 

Injury  of  the  spinal  cord,  on  a  level  with  the  eighth,  ninth,  or 
tenth  rib,  does  not  interfere  in  the  least  with  stomach  digestion,  but 
promptly  arrests  all  secretion  from  the  pancreas,  which  cannot  be 
excited  by  food  nor  by  the  presence  of  dextrine  in  the  stomach. 
Heidenhain  has  ascertained  that  stimulation  of  the  medulla  oblongata 
increases  the  flow  of  pancreatic  juice  as  well  as  its  active  constituents. 
These  experiments  show  that  the  reflex  action  of  the  stomach  upon 
the  pancreas  is  not  transmitted  through  the  sympathetic,  but  through 
the  spinal  cord. 

That,  the  essential  active  principle  of  the  pancreatic  juice  is 
necessary  for  digestion,  has  been  shown  by  Corvisart,  who  found  1  bat 
iii  <logs  the  pancreatic  juice  contained,  nine  and  a  half  hours  after  a 
meal,  no  ferment  which  was  capable  of  dissolving  albuminous  sul> 

1  Canstatt'a  Jahreebericht,  L861,  1-3,  |».  119. 


298  EXPERIMENTAL   SURGERY. 

stances.  If,  however,  the  animal  was  made  to  fast  for  a  longer 
time  than  this,  the  ferment  was  again  produced  in  some  unknown 
manner.  Pancreatic  digestion  becomes  apparent  six  or  seven  hours 
after  a  meal,  the  time  being  somewhat  dependent  upon  the  duration 
of  digestion. 

The  present  views  concerning  the  action  of  the  pancreatic  juice 
in  the  process  of  digestion  may  be  summarized  as  follows: 

1.  Starch  is  converted  by  a  diastatic  ferment  into  dextrine  and 
sugar,  a  continuation  of  the  action  of  the  saliva  in  the  intestine. 

2.  Melted  and  fluid  fats  are  emulsified  by  it  (a  property  which 
has  been  assigned  in  a  less  degree  to  bile) ;  at  the  same  time,  glycerine 
and  fatty  acids  are  formed  during  the  process.  The  emulsifying 
process  is  aided  by  the  fatty  acids  and  alkaline  salts  which  effect 
saponification  (Briicke,  Gad,  Quincke). 

3.  Albuminoid  substances  and  glue-containing  tissues,  when 
mixed  with  an  alkaline  solution,  are  dissolved  and  converted  into 
peptones  independently  of  stomach  digestion  (Corvisart).  A  portion 
of  the  peptones  undergoes  still  further  changes:  in  the  case  of 
albuminoid  substances,  leucin,  tyrosin,  xanthin,  and  sarcin;  in  the 
case  of  glue,  tyrosin,  glycin,  and  ammonium  may  appear. 

Fresh  pancreatic  juice  obtained  from  the  duct  of  Wirsung  is  a 
clear,  viscid,  alkaline,  highly  putrescible  fluid,  of  a  specific  gravity 
of  1.030,  which  solidifies  completely  on  boiling.  Pancreatic  juice 
contains:  1,  albumen;  2,  a  number  of  ferments;  3,  salts,  especially 
of  soda;  4,  water.  Sometimes  traces  of  self -digestion  of  the  juice 
can  be  found,  especially  leucin  (Herman).1 

The  pancreas  secretes  continually  in  herbivorous  animals;  in 
carnivorous,  only  during  digestion  (Heidenhain).  The  ferments  are 
only  present  in  the  gland,  trypsin  only  in  a  state  of  preparation,  a 
so-called  zymogen,  which,  on  division,  yields  trypsin;  this  division 
takes  place  on  exposure  of  the  gland  to  air,  the  action  of  oxygen, 
very  dilute  alkalies,  acids,  alcohol,  etc.  During  secretion  the  cells  of 
the  lobules  are  enlarged  while  the  latter  become  swollen;  at  the 
same  time  the  vessels  are  considerably  dilated. 

The  exact  quantity  of  pancreatic  juice  secreted  in  man  and  most 
animals  is  unknown.  From  a  practical  point  of  view,  it  is  impor- 
tant to  allude  to  the  effect  of  the  pancreatic  juice  upon  the  skin, 
s 

1  Lehrbuch  der  Physiologie,  Berlin,  1882.  p.  107. 


EXPERIMENTS   ON   THE  PANCREAS.  299 

which  it  macerates,  so  that  when  the  fluid  remains  in  contact  with 
the  skin  for  any  length  of  time  it  becomes  irritated  and  presents  a 
raw,  eczematous  surface.  It  also  appears  that  the  same  effect  is  not 
produced  when  it  is  brought  in  contact  with  the  peritoneum,  because 
in  this  locality  fresh  pancreatic  juice  is  removed  rapidly  by  absorp- 
tion. A  positive  diagnosis  of  disease  of  the  pancreas  will  only 
become  possible  when  more  attention  shall  have  been  bestowed  upon 
the  symptoms  arising  from  defective  digestion,  the  result  of  a  defec- 
tive or  faulty  function  of  the  pancreas — a  pancreatic  indigestion. 
Long-continued  indigestion  of  fatty  or  starchy  food  shoxild  be  con- 
sidered a  sufficient  indication  for  instituting  a  most  careful  search  for 
pancreatic  disease,  by  ascertaining  the  effect  upon  the  digestion  of 
particular  articles  of  diet,  and  by  examining  with  care  the  discharges 
from  the  bowels. 

IV.    Experiments  on  the  Pancreas. 

The  operative  treatment  of  injuries  and  diseases  of  the  pancreas 
belongs  to  the  future.  Until  now,  the  efforts  of  surgeons  have  been 
limited  to  the  treatment  of  a  few  cases  of  cysts  of  the  pancreas. 
The  results  obtained  in  these  cases  have  been  so  encouraging,  that 
undoubtedly  other  lesions  of  this  organ  will  soon  constitute  new 
indications  for  surgical  treatment. 

The  clinical  material  that  is  now  available  is  inadequate  to 
furnish  a  reliable  basis  for  new  operations;  on  this  accoimt  it  has 
been  my  object  to  obtain  new  light  by  subjecting  the  pancreas  to  a 
variety  of  surgical  procedures,  to  ascertain  the  tolerance  of  this 
organ  to  direct  treatment,  and  to  determine,  if  possible,  how  much 
of  the  gland  could  be  removed  with  safety  in  case  it  is  the  seat  of 
injury  or  disease.  The  object  of  these  experiments  also  included 
an  attempt  to  elucidate  the  causes  and  pathological  conditions  of 
some  of  the  well-recognized  lesions  of  this  organ. 

Dogs  and  cats  were  used  exclusively  as  subjects  of  these  experi- 
ments, as  a  few  trials  soon  satisfied  me  that  in  the  smaller  herbivora, 
as  the  rabbit  and  sheep,  the  pancreas  was  proportionately  small  and 
difficult  of  access.  The  operation  was  always  performed  under 
antiseptic  precautions,  with  the  exclusion  of  the  spray,  and  the  typical 
orthodox  dressing,  The  abdomen  was  always  shaved  and  disinfected 
with  a  solution  of  corrosive  sublimate;  ether  was  used  as  an  anas 


300  EXPERIMENTAL   SURGERY. 

thetic.  The  abdominal  incision  was  made  through  the  linea  alba, 
from  near  the  tip  of  the  xiphoid  cartilage  to  the  umbilicus. 
,  The  omentum  major  was  either  pushed  upward,  or,  in  the 
majority  of  cases,  an  opening  was  made  into  it  by  tearing  at  a  point 
opposite  the  external  incision.  The  guide  to  the  pancreas  was 
always  the  pyloric  orifice  of  the  stomach — after  the  index  finger  had 
reached  this  point,  it  was  passed  along  the  duodenum  for  three  or 
four  inches,  when  the  bowel  was  grasped  between  the  index  finger 
and  thumb  and  brought  with  the  pancreas  into  the  incision. 

If  any  considerable  prolapse  of  the  viscera  was  made  necessary 
to  accomplish  the  object  for  which  the  operation  was  made,  the 
exposed  organs  were  carefully  protected  with  a  compress  of  gauze 
wrung  out  in  a  warm  weak  solution  of  corrosive  sublimate  (1 :  2000). 
Irrigation  of  the  external  wound  and  protruded  organs  with  the  same 
solution  was  frequently  resorted  to,  to  cleanse  the  parts  of  blood,  and 
to  preserve  the  wound  in  an  aseptic  condition.  A  good  light  and  an 
empty  stomach  facilitated  the  operation  greatly. 

It  was  always  found  difficult  to  detach  the  pancreas  from  the 
duodenum  without  incurring  a  considerable  and  often  dangerous  loss 
of  blood.  To  prevent  this  occurrence  most  effectively,  blunt  dissec- 
tion and  direct  compression  with  a  moist,  hot,  aseptic  sponge,  proved 
the  most  effective  measures;  when  large  vessels  were  to  be  divided, 
double  prophylactic  ligation  was  often  resorted  to. 

After  completion  of  the  operation  the  pancreas  and  duodenum 
were  thoroughly  cleansed  and  dried,  and  the  toilet  of  the  peritoneal 
cavity  made  with  care;  the  abdominal  incision  was  closed  with  inter- 
rupted sutures  introduced  in  the  usual  manner  so  as  to  include  the 
peritoneum.  The  external  wound  was  sealed  with  a  small  compress 
of  iodoform  cotton  repeatedly  saturated  with  iodoform  collodium. 
At  the  end  of  a  week  the  sutures  were  removed.  Primary  union  of 
the  abdominal  incision  was  the  rule;  in  only  a  few  instances  healing 
of  the  wound  was  accomplished  by  granulation.  Ventral  hernia  was 
observed  in  a  number  of  cases. 

I.     Complete   Section   of  the   Pancreas. 

Complete  section  of  the  pancreas  was  made  an  object  of  experi- 
mentation, to  ascertain  whether  the  continuity  of  the  pancreatic 
duct  would  be  restored  after  complete  division  and  subsequent 
accurate  coaptation,  and  to  study  the  process  of  repair  between  the 


EXPERIMENTS   ON   THE  PANCREAS. 


30J 


divided  ends  of  the  pancreas.  The  section  was  made  transverseh  . 
and,  after  arresting  all  haemorrhage,  the  margins  of  the  wound  were 
brought  into  accurate  contact  with  deep  catgut  sutures,  which  were 
made  to  embrace  the  entire  thickness  of  the  organ. 

Experiment  1.  Dog,  four  and  one  half  months  old;  weight  thirty-five 
pounds.  Operation  performed  August  23,  1885.  Complete  division  of 
pancreas  transversely  through  the  middle  portion:  vessels  ligated  with  fine 
catgut,  the  haemorrhage  being  arterial  from  the  gastrosplenic,  and  venous 
from  the  duodenal  end.  Cut  surfaces  brought  together  accurately  with  fine 
catgut  sutures,  which  were  passed  through  the  entire  thickness  of  the  organ, 
about  one-third  of  an  inch  from  the  margins  of  the  visceral  wound.     Animal 


Fig.  4. 

a.     Point  of  section  and  coaptation  by  sutures. 
Sections  from  M,  gastrosplenic  portion,  show  parenchyma  cells  in  a 

state  of  fatty  degeneration.     Connective  tissue  increased. 
Sections  from  M,  duodenal  portion,  show  normal  structure.      At  a, 

narrow  band  of  cicatricial  tissue. 

showed  no  signs  of  suffering  or  disease  after  the  operation,  but  lost  four 
pounds  in  weight  during  the  first  eight  days.  After  this  time  the  animal 
began  to  increase  in  weight.  Highest  temperature  104  F.,  on  the  fourth  day. 
The  animal  was  killed  December  6,  1885,  one  hundred  and  five  days  after  the 
operation. 

An  examination  of  the  pancreas  showed  that  union  had  taken  place 
between  the  two  ends  by  means  of  a  narrow  cicatrix,  which  was  indicated  by 
a  slight  constriction  at  the  site  of  section.  Duodenal  portion  of  gland 
presented  a  normal  appearance,  as  the  section  had  been  made  or  the  splenic 
side  of  the  common  duct.   Gastrosplenic  end  aomewhal  at  rophic  and  sclerosed. 


302  EXPERIMENTAL   SURGERY. 

Pancreatic  duct  patent  to  cicatrix,  where  the  principal  duct  of  the  splenic 
portion  was  completely  obliterated.  No  dilatation  of  duct  in  the  splenic  end. 
(Fig.  4.) 

Experiment  2.  Adult  dog,  medium  size;  complete  section  of  pancreas 
through  the  junction  of  the  middle  with  the  splenic  end.  Only  artery  from 
splenic  end  required  ligation.  Immediate  coaptation  by  means  of  three  cat- 
gut ligatures  passed  through  substance  of  gland.  Animal  remained  well  after 
the  operation;  appetite  unimpaired.  Dog  was  killed  three  weeks  after  the 
operation;  abdominal  wound  completely  healed;  at  point  of  section  slight 
adhesions  to  neighboring  organs.  Visceral  wound  healed  by  a  linear  cicatrix 
of  young  connective  tissue.  Pancreatic  duct  completely  obliterated  at  site  of 
operation. 

Remarks. — These  operations  would  tend  to  show  that  complete 
division  of  the  pancreas,  when  not  complicated  by  other  and  more 
serious  lesions,  is  not  a  dangerous  accident,  if  the  only  source  of 
danger,  haemorrhage,  is  met  by  proper  surgical  treatment.  The 
coaptation  of  the  divided  ends  would  be  desirable,  but  is  not 
essential,  as  the  continuity  of  the  duct  is  not  restored  after  this 
injury.  No  disturbance  of  digestion  was  observed  in  either  case,  as 
an  adequate  amount  of  pancreatic  juice  was  secreted  from  the 
portion  of  the  gland  which  remained  in  communication  with  the 
lumen  of  the  intestine.  As  in  both  of  these  instances  a  greater  or 
less  amount  of  pancreatic  juice  must  have  escaped  into  the  peritoneal 
cavity  from  the  cut  surfaces,  and  perhaps  later  fro  in  the  divided 
duct  of  the  splenic  end,  we  have  thus  early  evidence  of  the  innocuity 
of  extravasation  of  pancreatic  juice  into  the  peritoneal  cavity.  The 
process  of  repair  was  in  both  instances  accomplished  by  the  inter- 
position of  a  linear  cicatrix  between  the  divided  and  coaptated  ends. 

Although  accurate  approximation  was  effected  by  three  sutures, 
transfixing  the  entire  thickness  of  the  gland  by  passing  the  needle 
from  before  backward  on  one  side,  and  from  behind  forward  on  the 
other,  it  seems  that  primary  union  between  the  divided  ends  failed 
to  take  place,  and  that  the  process  of  repair  was  accomplished  by 
connective  tissue  proliferation  from  the  connective  tissue  on  the 
surface  of  the  wound,  a  process  necessarily  accompanied  by  a  simul- 
taneous degeneration  of  the  parenchyma  of  the  gland,  over  an  area 
corresponding  to  the  seat  of  cicatrization. 

Microscopical  examination  of  sections  made  in  close  proximity 
to  the  cicatrix,  showed  various  degrees  of  degenerative  changes  in 
the  cells  of  the  parenchyma,  with  a  corresponding  space  of  connec- 
tive tissue  proliferation. 


EXPERIMENTS    ON    THE   PANCREAS.  303 

Complete  section  of  the  duct,  even  when  the  ends  are  kept  in 
accurate  coaptation,  appears  to  result  uniformly  in  the  obliteration 
of  the  duct  at  the  site  of  section.  The  obliteration  is  the  direct 
result  of  the  formation  of  a  cicatrix  in  the  lumen  of  the  duct  from 
the  cut  surfaces.  In  both  specimens  the  length  of  the  cicatrix — 
consequently  the  extent  of  impermeability  of  the  duct — corresponds 
to  the  length  of  the  cicatrix  interposed  between  the  divided  ends  of 
the  gland. 

The  practical  deductions  to  be  obtained  from  these  experi- 
ments are:  That  in  transverse  visceral  wounds  of  the  pancreas,  the 
most  important  indication  that  presents  itself,  is  to  arrest  haemor- 
rhage by  ligating  the  bleeding  vessels,  and  to  resort  to  suturing  of 
the  severed  organ  with  a  view  to  retain  both  ends  of  the  pancreas 
as  nearly  as  possible  in  their  normal  location,  and  thus  maintain  as 
nearly  as  possible  the  integrity  of  the  vascular  supply,  rather  than 
with  the  purpose  of  obtaining  restoration  of  continuity  of  the  divided 
pancreatic  duct,  which,  if  it  could  be  accomplished,  would  preserve 
the  physiological  importance  of  the  detached  portion  of  the  gland. 
By  the  detached  portion  of  the  gland,  I  mean  that  portion  which  no 
longer  remains  in  physiological  connection  with  the  intestine,  and 
which  never  regains  its  physiological  importance  after  the  duct  has 
become  obliterated  by  a  cicatrix  at  the  point  of  section. 

2.     Laceration  of  the  Pancreas. 

Having  observed  that  complete  section  of  the  pancreas  is 
followed  by  severe  haemorrhage,  both  arterial  and  venous,  which 
undoubtedly  might  prove  a  source  of  no  inconsiderable  danger  in 
cases  of  similar  wounds  of  the  organ  in  man,  the  following  experi- 
ment was  made  to  ascertain  the  extent  of  haemorrhage  after 
laceration  of  this  organ,  without  the  intervention  of  treatment: 

hj.ijtpritnp)i!  3.  Large  adult  cat;  weight  seven  and  one-half  pounds. 
Abdomen  opened  through  the  median  line,  the  pancreas  exposed  and  detached 
sufficiently  from  the  duodenum  at  the  junction  of  the  middle  with  the  duo- 
denal end,  where  it  was  torn  completely  across  and  the  bleeding  ends  dropped 
into  the  abdominal  cavity;  the  wound  was  closed  in  the  usual  manner. 

The  haemorrhage  was  noticed  to  be  much  less  than  after  section.  Highest 
temperature  104.fi  F.,  two  days  after  operation.  No  symptoms  of  hemor- 
rhage <>i  peritonitis.  On  the  removal  of  the  sutures  the  abdominal  incision 
had  apparently  closed.  Six  days  Liter  the  wound  opened,  and  it  was  reported 
tli't  one  end  of   the  pancreas  had  protruded  from  the  wound.     The  prolapsed 


304  EXPERIMENTAL   SURGERY. 

viscus  and  wound  were  disinfected,  the  organ  replaced,  and  the  opening  closed 
with  sutures. 

The  animal  did  not  appear  to  be  very  ill,  but  died  two  days  later.  At  the 
autopsy  no  effusion  was  found  in  the  peritoneal  cavity  and  no  signs  of  general 
peritonitis.  A  portion  of  the  duodenum  appeared  gangrenous.  The  lacerated 
end  of  the  splenic  portion  was  adherent  to  the  duodenum  at  a  point  two  inches 
below  the  pyloric  orifice  of  the  stomach.  The  duodenal  portion  was  very 
much  atrophied  and  drawn  up  toward  the  splenic  portion,  and  united  to  it  by 
an  extensive  mass  of  cicatricial  tissue.  On  opening  the  pancreatic  duct  from 
the  duodenum,  no  communication  could  be  found  between  it  and  the  gastro- 
splenic  portion  of  the  gland. 

Remarks. — Death  in  this  case  resulted  from  the  accidental 
reopening  of  the  abdominal  wound.  The  prolapsed  organ  was,  in 
all  probability,  the  duodenum  and  not  the  pancreas;  the  gangrene 
of  the  intestine  was  undoubtedly  caused  by  the  prolapse  and  strangu- 
lation before  the  bowel  was  replaced.  The  laceration  of  the  pancreas 
was  made  at  a  point  where  the  two  ducts  meet;  hence  the  imper- 
meability of  the  duct  in  the  gastro- splenic  portion  of  the  pancreas. 
Haemorrhage  was  arrested  spontaneously,  and  the  process  of  repair, 
so  far  as  the  wound  in  the  pancreas  was  concerned,  appeared  to  be 
satisfactory.  The  divided  ends  were  displaced  considerably  imme- 
diately after  the  laceration,  but  were  subsequently  brought  into 
close  contact  by  the  cicatricial  contraction. 

3.     Comminution  of  the  Pancreas. 

It  has  been  asserted  by  a  number  of  authorities  that  dead  pan- 
creatic tissue  is  a  highly  putrescible  substance,  and  on  this  account 
its  presence  is  very  liable  to  serve  as  a  source  of  infection. 

Believing  that  putrefaction  can  never  occur  without  the  specific 
germs,  even  in  the  case  of  dead  and  highly  putrescible  substances, 
the  following  experiments  were  made  to  test  the  correctness  of  this 
assertion: 

Experiment  4.  Maltese  cat;  weight  three  and  a  quarter  pounds.  Oper- 
ation September  18,  1885.  The  pancreas,  with  its  vessels,  was  completely 
detached  from  the  duodenum  to  the  extent  of  two  inches,  about  the  middle  of 
the  gland.  The  isolated  portion  was  completely  crushed  between  the  blades 
of  a  sequestrum  forceps.  No  haemorrhage  whatever  occurred,  and  the  organ 
was  dropped  into  the  abdominal  cavity.  The  day  after  the  operation  the 
temperature  rose  to  105°  F.,  but  the  next  day  it  was  normal,  and  remained  so 
until  the  killing  of  the  animal,  December  13,  eighty-six  days  after  the 
operation. 


EXPERIMENTS    ON    THE   PANCREAS. 


305 


No  evidences  of  diffuse  peritonitis,  only  slight  adhesions  where  the  gland 
had  been  crushed.  The  duodenal  portion  was  atrophied  and  drawn  toward 
the  gastrosplenic  portion,  to  which  it  was  united  by  a  firm  cicatrix,  which 
united  the  two  ends  of  the  gland  to  the  duodenum,  thus  completing  the  mesen- 
teric attachment  of  the  bowel.  The  cicatrix  a,  showed  a  line  of  pigmentation 
throughout  its  entire  thickness.  (Fig.  5.)  The  crushed  portion  of  the  gland 
had  disappeared  entirely  by  absorption,  and  its  place  was  occupied  by  a  firm 
cicatrix,  which,  by  contraction,  had  approximated  both  portions  of  the  gland. 
The  crushing  was  done  below  the  point  of  entrance  of  the  pancreatic  duct, 
which  caused  the  atrophy  of  the  duodenal  portion,  which  was  no  longer  in 
physiological  connection  with  the  duodenum. 


Fig.  5. 

a.   Point  where  gland  was  crushed. 

Sections  from  M  show  normal  tissue. 

Sections  from  M '  show  fatty  degeneration  and  sclerosis. 


Experiment  5.  Young  cat;  weight  two  and  a  half  pounds.  Pancreas 
brought  into  the  abdominal  incision,  with  a  loop  of  the  duodenum;  without 
separating  it  from  the  bowel  it  was  crushed  at  its  middle  to  the  extent  of  two 
inches,  between  the  blades  of  a  sequestrum  forceps.  No  haemorrhage  followed 
the  procedure,  and  the  organ  was  dropped  back  into  the  abdominal  cavity. 
The  animal  had  been  in  a  bad  condition  before  the  operation,  and  died  seven 
days  later.  At  the  autopsy  the  abdominal  incision  was  found  closed.  No 
peritonitis  or  effusion.  Crushed  portion  showed  no  signs  of  suppuration,  but 
appeared  thicker  and  shorter  than  after  the  crushing:  a  change  which  was 
attributed  to  the  infiltration  of  the  dead  tissue  by  Leucocytes,  and  connective 
20 


•306  EXPERIMENTAL   SURGERY. 

tissue  proliferation.  The  two  ends  of  the  gland  were  brought  into  closer 
contact  by  contraction  of  the  recent  cicatrix,  which  had  also  the  effect  of 
doubling  the  duodenum  upon  itself. 

Remarks. — In  both  instances  the  crushed  parenchyma  of  the 
organ  was  promptly  removed  by  absorption,  which  seems,  in  this 
particular  locality,  to  proceed  with  unusual  activity,  an  occurrence 
which  can  only  be  explained  by  the  assumption  that  the  peritoneum 
is  active  in  this  process.  No  infection  took  place,  and  no  evidence 
of  putrefaction  could  be  found.  Should  wound  infection  take  place 
in  cases  of  this  kind,  there  can  be  no  doubt  that  the  dead  pancreatic 
tissue  would  serve  as  a  most  favorable  soil  for  the  septic  germs,  and 
would  thus  create  the  most  essential  condition  for  the  rapid  and 
most  dangerous  form  of  infection. 

These  experiments  also  serve  to  demonstrate  that  subcutaneous 
crashing  or  comminution  of  the  pancreas  is  in  itself  not  a  fatal  or 
even  dangerous  injury.  Subcutaneous  comminution  can  only  prove 
dangerous  from  the  site  of  the  injury,  as,  for  instance,  when  the 
crushing  takes  place  at  or  near  the  outlet  of  the  pancreatic  duct, 
where,  from  cicatricial  contraction,  obstruction  of  the  duct  takes 
place,  which  would  interfere  with  the  normal  escape  of  pancreatic 
juice  from  the  intact  portion  of  the  gland.  If  the  comminuted  tissue 
remains  in  an  aseptic  condition,  it  is  removed  by  absorption,  and 
the  loss  of  substance  is  at  least  partially  replaced  by  connective 
tissue,  which  forms  a  bridge  between  the  intact  portions  of  the 
gland.  Subsequent  degeneration,  atrophy,  and  sclerosis  take  place 
in  that  portion  of  the  gland  which  is  no  longer  connected  with  the 
intestine  by  a  permeable  duct. 

4.     Complete   Extirpation   of  the   Pancreas. 

A  diversity  of  opinion  still  prevails  among  physiologists  in 
regard  to  the  immediate  and  remote  effects  of  complete  extirpation 
of  the  pancreas,  or  an  artificial  sudden  suspension  of  its  functions. 
The  results  obtained  by  different  experimenters  have  led  to  diverse 
conclusions.  Some  claim  for  the  pancreas  an  essential  part  in  the 
process  of  digestion,  while  others  affirm  with  equal  positiveness  that 
the  gland  can  be  removed  or  rendered  physiologically  incompetent 
without  impairing  digestion.      Bernard1  found  that  extirpation  of 

1  Memoire  sur  le  Pancreas,  p.  157. 


EXPERIMENTS   ON   THE  PANCREAS.  307 

the  pancreas  in  birds  produced  death  by  marasmus  in  eight  or  ten 
days. 

Berard  and  Colin  removed  the  pancreas  in  a  duck,  and,  on 
examining  the  animal  six  months  later,  found  the  site  of  the  pancreas 
occupied  by  a  thin  layer  of  fat,  which  contained  a  few  reddish 
nodules.  No  connection  could  be  traced  between  them  and  the 
intestine. 

In  pigs,  part  of  the  pancreas  lies  upon  the  portal  vein,  and  the 
authors,  therefore,  removed  only  the  portion  adjacent  to  the  duodenum. 
In  one  animal  which  died  a  few  weeks  after  the  operation  from  acci- 
dental causes,  they  found  in  place  of  the  portion  of  the  pancreas 
removed,  a  cyst,  the  size  of  a  hen's  egg,  which  had  no  communica- 
tion with  the  duodenum,  and  was  filled  with  a  fluid  which,  like 
pancreatic  juice,  was  coagulated  by  alcohol. 

In  a  second  case  operated  upon  in  a  similar  manner,  the  weight 
of  the  animal  increased  in  five  and  a  half  months,  twenty-five  kilo- 
grammes. When  the  animal  was  killed,  only  a  trace  of  the  pan- 
creatic duct  could  be  discovered.  The  portion  of  the  gland  left  had 
undergone  atrophy,  and  contained  no  ducts.  The  atrophied  portion 
was  eight  to  ten  centimeters  distant  from  the  duodenum,  and  one 
section  gave  evidence  of  having  undergone  sclerosis. 

In  five  young  dogs  the  pancreas  was  extirpated,  leaving  only 
that  portion  which  lies  upon  the  portal  vein.  All  the  animals 
remained  well  at  the  end  of  eight  months.  Three  of  the  dogs  were 
killed.  In  two  of  them  the  autopsy  showed  that  the  terminal 
extremity  of  the  pancreatic  duct  remained  as  a  blind  pouch.  The 
part  of  the  gland  left  had  become  very  much  atrophied,  and  remained 
isolated  from  the  duodenum.  A  glandular  structure  as  large  as  a 
bean  was  found  near  the  duodenum  in  both  dogs;  in  one  of  them  a 
duct  connected  this  body  with  the  bowel,  while  in  the  other  no  such 
connection  could  be  traced.  Taking  it  for  granted  that  these  small 
bodies  were  composed  of  pancreatic  tissue,  their  weight  being  only 
about  one-ninetieth  part  of  the  whole  gland,  the  amount  of  secretion 
from  them  would  not  have  been  sufficient  to  emulsify  the  fats. 

In  the  third  dog  no  trace  of  the  pancreas  could  bo  found,  and 
yet  the  animal's  digestion  and  health  appeared  to  be  normal.  The 
faeces  contained  no  undigested  fat.  From  these  and  other  experi- 
ments of  the  same  kind,  the  authors  came  to  the  conclusion  that  the 
presence  of  the  pancreatic  juice  is  not  essential   in  the  process  of 


308  EXPERIMENTAL  SURGERY. 

digestion  or  absorption  of  fat  in  herbivorous,  carnivorous,  or 
omnivorous  animals,  or  in  birds. 

Schiff  brought  about  complete  suspension  of  the  function  of 
the  pancreas  in  animals  without  removing  any  part  of  the  organ,  by 
injecting  the  ducts  of  the  gland  with  melted  paraffin,  which,  at  the 
temperature  of  the  body,  became  a  solid  mass,  completely  obstruct- 
ing the  outlets  for  the  secretion.  Animals  treated  in  this  manner 
showed  no  signs  of  derangement  of  digestion,  and  were  able  to 
assimilate  fat  as  well  as  healthy  animals. 

The  following  experiments  were  made  to  ascertain  the  feasibility 
of  complete  extirpation  of  the  pancreas,  and  the  effects  of  such 
a  procedure  upon  digestion  and  assimilation.  In  all  of  the  experi- 
ments the  entire  organ  was  removed.  The  hemorrhage  was  always 
profuse,  and  required  numerous  catgut  ligatures  for  its  arrest. 

The  larger  vessels  between  the  duodenum  and  pancreas  were 
carefully  isolated  and  removed  with  the  gland,  so  that  the  intestine 
was  deprived  of  its  direct  vascular  supply  over  an  area  corresponding 
to  the  extent  of  the  attachment  of  the  pancreas. 

Experiment  6.  Brown  dog,  four  and  a  half  months  old;  weight  thirty- 
two  pounds.  The  entire  pancreas  was  extirpated,  part  of  the  dissection  was 
made  with  Paquelin's  cautery.  Temperature  on  second  day  104°  F.,  on  fifth 
day  101.2°  F.  (subnormal).  On  the  fourth  day  diarrhoea  set  in;  stools  con- 
tained undigested  food  and  free  fat,  and  on  the  seventh  day  blood.  On  the 
ninth  day  the  animal  died.  During  the  first  few  days  the  appetite  remained 
unimpaired,  but  when  the  diarrhoea  supervened  food  was  taken  only 
sparingly. 

At  the  autopsy  it  was  ascertained  that  the  animal  had  lost  five  pounds  in 
weight.  The  abdominal  cavity  contained  a  considerable  quantity  of  bloody 
serum,  and  the  peritoneum  presented  evidences  of  recent  diffuse  peritonitis. 
The  duodenum  showed  several  dark  spots  on  its  convex  surface,  which  might 
be  taken  for  beginning  gangrene.  The  pancreatic  duct,  traced  from  within 
the  duodenum,  was  found  closed  at  the  point  of  section  by  a  cicatrix  upon  the 
outer  surface  of  the  bowel.*  Whether  in  this  case  the  diarrhoea  resulted  from 
the  absence  of  the  pancreatic  juice  or  from  the  septic  peritonitis,  would  be 
difficult  to  determine.  The  duodenum  had  been  detached  from  its  mesentery 
at  least  ten  inches,  and  yet  the  gangrene,  if  any,  after  nine  days  was  limited 
to  a  few  circumscribed  patches. 

Experiment  7.  Large  black  dog,  four  months  old;  weight  forty -eight 
pounds.  Experience  had  proved  that  the  separation  of  the  pancreas  and  its 
vessels  from  the  duodenum  could  be  done  more  safely,  and  with  less  risk  of 
haemorrhage,  by  tearing  the  tissues  instead  of  using  the  scissors  or  knife, 
employing  the  cutting  instruments  only  when  it  was  thought  imprudent  to  use 


EXPERIMENTS   ON   THE   PANCREAS.  309 

too  much  violence  in  separating  strong  connecting  bands,  which  would  not 
yield  to  gentle  force.  In  this  case  twelve  ligatures  were  required  to  arrest  the 
haemorrhage;  in  later  experiments  a  much  smaller  number  was  found  suffi- 
cient to  arrest  the  bleeding,  after  I  had  learned  to  rely  more  freely  on  the 
tearing  method  in  partial  and  complete  extirpation  of  the  pancreas.  This 
dog  never  recovered  fully  from  the  operation  and  died  on  the  fourth  day,  the 
temperature  having  remained  subnormal  during  the  whole  of  this  time. 

At  the  autopsy  a  perforation  in  the  duodenum  was  found  on  the  convex 
side  about  five  inches  below  the  pylorus;  recent  peritonitis,  which  was 
undoubtedly  produced  by  extravasation  consequent  upon  the  perforation; 
gangrene  of  the  bowel,  circumscribed  and  limited  to  the  seat  of  perforation, 
and  a  few  other  small  spots  on  the  convex  surface  of  the  bowel.  Pancreatic 
duct  at  point  of  section  not  closed.  In  this  case  death  was  directly  attribut- 
able to  gangrene  of  the  duodenum,  caused  by  the  extensive  detachment  of  its 
mesenteric  vascular  supply. 

Experiment  S.  Large  adult  cat.  The  operation  occupied  more  than  half 
an  hour,  and  was  attended  by  considerable  haemorrhage  from  the  deep  attach- 
ments of  the  gastrosplenic  end.  The  bleeding  was  finally  arrested  by  ligating 
a  number  of  vessels  in  the  region  of  the  spleen.  The  animal  never  rallied  from 
the  operation  and  died  five  hours  later  with  symptoms  of  haemorrhage  and 
shock  combined.  On  opening  the  abdomen  no  blood  was  found  in  the 
peritoneal  cavity,  except  a  few  flat  coagula  which  covered  the  denuded  surface 
of  the  bowel,  which  extended  seven  inches  in  length. 

Experiment  9.  Adult  female  cat.  The  extirpation  was  again  attended  by 
free  haemorrhage,  and  the  animal  died  half  an  hour  after  the  completion  of  the 
operation,  with  symptoms  of  haemorrhage  and  shock. 

Experiment  10.  Adult  black  dog;  weight  thirty-three  pounds.  Animal 
remained  comparatively  well  for  two  days,  when  peritonitis  supervened,  which 
proved  fatal  on  the  fourth  day  after  the  operation.  Wound  closed;  peritoneal 
surfaces  separated  with  some  difficulty.  The  abdominal  cavity  contained  a 
quart  of  purulent  fluid.  At  the  same  time,  diffuse  general  peritonitis  had 
given  rise  to  extensive  adhesions  between  the  different  abdominal  organs.  The 
duodenum  appeared  quite  vascular  and  showed  no  signs  of  gangrene. 

Experiment  11.  Medium-sized  adult  cat.  After  the  extirpation  of  the 
entire  pancreas,  the  duodenum  was  found  on  measurement  to  have  been 
denuded  of  its  mesenteric  attachment  to  the  extent  of  seven  inches.  The 
venous  oozing  proved  free,  and  could  not  be  completely  arrested  during  the 
time  which  it  was  deemed  prudent  to  keep  the  abdominal  organs  exposed  to 
the  atmospheric  air.  The  animal  never  rallied  from  the  operation  and  died 
two  hours  later.  On  opening  the  abdominal  cavity,  a  considerable  quantity  of 
fluid  venous  blood  was  found.  In  this  case  death  was  caused  by  uncon- 
trollable venous  hemorrhage. 

Kimakks. — It  will  be  seen  that  of  six  animals  subjected  to  com- 
plete extirpatiOD  of  Hie  pancreas,  in  all  cases  death  occurred  in  from 
a  few  hours  to  nine  days  after  the  operation.     The  cause  of  death 


310 


EXPERIMENTAL  SURGERY. 


was  either  the  primary  effects  of  the  traumatism,  hemorrhage,  and 
shock,  or  from  secondary  pathological  lesions  traceable  directly  to 
the  operation,  as  may  be  readily  gleaned  from  the  following  table: 


No. 

Animal. 

Time  of  death. 

Cause  of  death. 

1 
2 
3 
4 
5 
6 

Dog, 

Cat, 

Dog, 
Cat, 

9  days, 

4  " 

5  hours, 

30  minutes, 
4  days, 
2  hours, 

Peritonitis. 

Gangrene  of  duodenum. 

Haemorrhage  and  shock. 

«                    u            a 

Purulent  peritonitis. 
Haemorrhage. 

This  table  shows  that  the  operation  on  cats  proved  more  danger- 
ous than  on  dogs,  and  of  the  three  animals  all  died  within  five  hours 
from  the  immediate  effects  of  shock  and  haemorrhage.  The  three 
dogs  died  of  peritonitis  within  from  four  to  nine  days.  In  one  case 
the  peritonitis  was  due  to  perforation,  in  the  remaining  two  it  was 
produced  through  either  the  wound  or  the  pancreatic  duct,  which 
was  found  open  in  one  of  the  cases. 

The  complete  extirpation  of  the  pancreas  necessitates  such  an 
extensive  separation  of  the  intestine  from  the  mesentery,  that  this 
alone  constitutes  a  great  source  of  danger,  as  gangrene  may  take 
place.  It  is  important  to  repeat  that  in  the  two  specimens  which 
showed  evidences  of  gangrene  this  was  observed  on  the  convex 
surface  of  the  bowel,  and  in  neither  case  did  it  involve  the  entire 
diameter  of  the  intestine.  It  requires  no  explanation  to  show  that 
in  cases  of  this  kind  the  collateral  circulation  is  established  first  on 
the  concave  side,  where  the  vascular  supply  is  nearest  and  the  force 
of  the  circulation  most  vigorous. 

In  dogs  and  cats  the  pancreas  is  attached  so  intimately  and 
extensively  to  the  duodenum  that  complete  extirpation  is  necessarily 
attended  by  profuse  hemorrhage,  which  often  was  found  difficult, 
and  in  one  instance  impossible,  to  control.  Ligation  of  some  of  the 
bleeding  points  was  often  found  impossible,  as  any  attempt  at  seizing 
the  vessel  necessarily  grasped  the  muscular  coat  of  the  bowel,  which 
it  was  thought  to  be  dangerous  to  include  in  the  ligature,  as  it  might 
give  rise  to  perforation.  Steady  pressure  with  a  sponge  wrung  out 
of  a  hot,  weak  solution  of  corrosive  sublimate  was  found  to  be  the 
most  reliable  means  in  arresting  troublesome  oozing.     None  of  these 


EXPERIMENTS   OX    THE   PANCREAS.       «  311 

experiments  was  sufficiently  successful  to  study  the  effect  of  complete 
extirpation  of  the  pancreas  upon  digestion  and  assimilation.  In  a 
number  of  the  autopsies,  however,  the  lacteals  contained  a  milky 
fluid,  showing  that  at  least  a  portion  of  the  fatty  food  had  been 
emulsified  by  other  secretions. 

As  a  final  conclusion,  I  do  not  hesitate  to  affirm  that  in  dogs 
and  cats  complete  extirpation  of  the  pancreas  is  always  followed  by 
death,  either  from  the  primary  effect  of  the  operation,  or  the  second- 
ary consequences  following  it. 

5.     Partial  Extirpation  of  the  Pancreas. 

Partial  extirpation  of  the  pancreas  implies  a  less  degree  of 
traumatism,  and  consequently  less  danger  of  causing  serious  nutri- 
tive changes  in  adjacent  organs  than  complete  extirpation,  and  for 
these  reasons  it  is  less  dangerous,  in  a  strictly  surgical  sense.  Physi- 
ologically, a  partial  extirpation  of  the  organ  may  imply  the  same 
consequences  as  complete  extirpation,  as  when  the  portion  of  gland 
removed  embraces  the  common  duct  or  both  principal  ducts  from 
each  portion  of  the  gland. 

Experiment  12.  Adult  cat;  weight  six  and  a  half  pounds.  Pancreas 
drawn  into  the  abdominal  wound  with  the  duodenum,  and  separated  from  the 
bowel  to  the  extent  of  two  inches,  at  a  point  corresponding  to  the  middle 
portion  of  the  gland.  This  section  of  the  gland,  which  included  the  termi- 
nation of  the  ducts,  was  excised  with  Paquelin's  cautery;  only  one  artery  from 
the  gastrosplenic  end  required  ligature;  ends  of  gland  dropped  into  the 
abdominal  cavity.  The  temperature  remained  subnormal,  101  F.,  until  the 
animal  died,  two  days  after  the  operation.  At  the  autopsy,  gangrene  and 
perforation  of  the  duodenum  were  found  at  a  point  corresponding  to  the  site 
of  resection. 

Experiment  13.  Scotch  terrier;  weight  twenty-live  and  a  half  pounds. 
Ligated  pancreas  at  its  middle,  with  catgut,  and  extirpated  the  gastrosplenic 
portion;  eight  ligatures  were  required  to  control  the  haemorrhage  and  about 
four  inches  of  the  duodenum  were  denuded  of  its  mesentery.  Second  day 
aftei  th<-  operation  the  temperature  was  100.4'  F.,  which  became  normal 
(108  F.i  on  third  day.  During  the  iirst  week  the  animal  gained  one  pound 
in  weight,  showing  that  digestion  was  not  disturbed  by  the  absence  of  the 
pancreatic  juice  during  this  time. 

Three  weeks  after  the  operation  the  dog  began  to  lose  flesh;  the  emaoia 
tion  was  progressive  until  the  animal  died  of  marasmus  seventy-six  days  aftei 
th<-  operation.     During  this  time  the  appetite  was  not  impaired,  and  al  no 
rim''   had   diarrhoea  been  observed.     The  organs  of  the  chest  were  found  in  a 
normal  condition.    The  abdominal  wound  was  firmly  united.    A  few  adhesions 


312  EXPERIMENTAL  SURGERY. 

between  the  omentum  and  parietal  peritoneum.  No  signs  of  peritonitis.  The 
parenchyma  of  the  duodenal  portion  of  the  gland  had  disappeared  completely 
by  absorption,  only  the  connective  tissue  and  the  duct,  somewhat  dilated, 
remaining. 

The  idea  that  degeneration  and  absorption  of  the  parenchymatous  struct- 
ure of  the  gland  were  caused  by  local  anaemia  could  not  be  entertained  for  a 
moment,  as  the  connective  tissue  frame  of  the  gland  was  freely  supplied  with 
numerous  and  large  vessels.  The  portion  of  the  duodenum  stripped  of  its 
mesentery  was  repaired  by  a  vascular  strip  of  connective  tissue,  which  restored 
the  continuity  of  the  mesenteric  circulation.  The  common  pancreatic  duct 
was  found  obliterated  at  its  point  of  entrance  into  the  bowel,  where  it  had 
been  divided  during  the  operation. 

Experiment  14.  Adult  cat;  weight  six  pounds.  .Extirpation  of  gastro- 
splenic  and  half  of  the  duodenal  portion  of  the  pancreas,  with  separation  of 
duodenal  mesentery  to  the  same  extent.  The  portion  of  the  gland  which 
remained  was  not  ligated.  The  animal  rallied  from  the  immediate  effects  of 
the  operation,  but  died  eighteen  hours  later  in  convulsions.  At  the  autopsy 
the  mucous  membrane  of  the  duodenum  in  the  portion  of  the  bowel  which  had 
been  deprived  of  its  direct  vascular  supply,  presented  a  cyanosed  appearance, 
but  no  distinct  signs  of  gangrene.  Abdominal  cavity  contained  no  fluid  of 
any  kind;  peritoneum  normal  in  appearance.  Slight  haemorrhage  between 
peritoneum  and  transversalis  fascia. 

Experiment  15.  Large  adult  dog;  weight  forty-eight  pounds.  Extirpa- 
tion of  two-thirds  of  the  pancreas  with  the  common  duct,  leaving  only  a  por- 
tion of  the  remote  end  of  the  gastrosplenic  portion.  The  haemorrhage,  which 
was  profuse,  was  carefully  arrested,  and  the  pancreas  ligated  before  section. 
The  first  two  days  the  temperature  was  subnormal,  101°-102.2°  F.  On  the 
third  day  it  became  normal  and  remained  so.  The  animal  remained  in  perfect 
health  for  four  weeks,  when  he  commenced  to  lose  flesh.  Appetite  voracious. 
No  diarrhoea,  but  stools  contained  undigested  fat.  Although  the  animal  ate  as 
much  as  four  dogs  of  similar  size,  emaciation  continued  and  had  become 
extreme  when  the  dog  was  killed,  one  hundred  and  twenty-six  days  after  the 
operation. 

At  the  autopsy  the  abdominal  incision  was  found  adherent  to  the  mesen- 
tery. The  duodenum  which  had  been  stripped  of  its  mesentery  was  found 
free,  without  a  mesenteric  attachment,  but  freely  supplied  with  blood  by  two 
large  vessels  running  through  a  band  of  connective  tissue  adherent  to  the 
bowel  on  the  concave  denuded  side.  The  vessels  were  in  communication  with 
the  adjacent  intact  mesenteric  vessels,  and  served  to  complete  the  interrupted 
mesenteric  circulation.  The  gastrosplenic  portion  of  the  gland  which  was  left 
behind  was  found  completely  atrophied;  in  its  center  the  duct  could  be  seen 
dilated  to  the  size  of  a  lead-pencil,  and  distended  by  a  clear,  transparent  fluid. 
The  dilated  duct  had  no  communication  with  the  bowel.     (Fig.  6.) 

Remarks. — As  in  all  of  these  experiments,  the  common  ducts 
were  removed  with  the  excised  portion  of  the  pancreas,  it  left  the 


EXPERIMENTS   ON   THE   PANCREAS. 


313 


animal  physiologically  in  the  same  condition  as  after  complete  extir- 
pation of  the  organ,  as  no  pancreatic  juice  conld  find  its  way  into 
the  intestine.  In  experiments  13  and  15  the  dogs  lived  for  a  sulfi- 
cient  length  of  time  to  determine  the  influence  of  the  pancreatic 
secretion  upon  digestion  and  assimilation.  In  both  of  these  animals 
the  general  health  and  nutrition  remained  unimpaired  for  four 
weeks,  when  emaciation,  with  fatty  stools,  followed,  which  resulted 
in  death  from  marasmus  in  one,  after  seventy-six  days,  and  reduced 
the  second  dog  to  a  skeleton  in  one  hundred  and  twenty-six  days. 


Fig.  6. 

a.  Remnant  of  pancreas. 

b.  Dotted  lines,  outlines  of  normal  position  of  gland. 

c.  Connective  tissue  nodule. 

d.  Duct. 

e.  Spleen. 

As  from  the  beginning  no  pancreatic  juice  found  its  way  into 
the  intestine,  it  is  difficult  to  account  for  the  satisfactory  condition 
of  digestion,  and  the  appearance  of  health  of  the  animals  for  the 
first  four  weeks,  followed  by  a  progressive  marasmus  and  increase  of 
appetite.  It  is  true  that  by  the  resection  of  the  mesentery  of  the 
duodenum  intestinal  absorption  was  correspondingly  diminished, 
I mt  marasmus  from  this  source  ought  to  have  manifested  itself  soon 
after  the  operation.  It  is  now  generally  conceded  that  a  health} 
pancreas  will  absorb  its  own  secretion  in  case  there  is  any  obstruction 


314  EXPERIMENTAL  SURGERY. 

to  prevent  the  normal  escape  of  the  pancreatic  juice,  and  it  may  be 
that  pancreatic  juice  entering  the  circulation  in  this  manner  may 
have  some  as  yet  unexplained  action  on  digestion.  Should  this  be 
the  case,  we  might  assume  that  the  pancreatic  tissue  left  behind  con- 
tinued to  secrete  until  the  parenchyma  was  incapacitated  by  degenera- 
tive changes  from  performing  this  function. 

All  of  the  above  experiments  made  on  the  pancreas  tend  to 
prove  that  any  portion  of  the  gland  when  it  becomes  detached  from 
the  bowel,  invariably  undergoes  degenerative  changes,  and  that  its 
parenchymatous  structure  disappears  by  absorption  within  a  few 
weeks.  In  these  cases  we  may  safely  assume  that  the  remaining 
portion  of  the  gland  had  been  rendered  physiologically  incompetent 
during  the  first  four  weeks,  the  time  during  which  the  animals 
remained  in  a  healthy  condition.  In  experiment  15  almost  the  entire 
duodenum  had  been  suddenly  deprived  of  its  vascular  supply,  and 
yet  no  gangrene  occurred.  The  collateral  circulation  was  established 
by  the  development  of  two  large  vessels  in  a  band  of  cicatricial 
tissue  along  the  concave  surface  of  the  bowel,  which  restored  the 
interrupted  circulation  between  the  mesenteric  vessels  on  each  side  of 
the  resected  portion  of  the  mesentery.  It  is  also  important  to  men- 
tion that  in  both  dogs  the  lacteals  appeared  empty  at  the  autopsy. 

These  experiments  would  then  tend  to  prove  that  the  pancreatic 
secretion  is  an  important,  if  not  essential,  digestive  fluid,  and  that 
in  cases  where  no  pancreatic  juice  can  enter  the  intestine,  or  where 
the  secretion  is  entirely  suspended,  digestion  and  assimilation  become 
impaired  in  all  cases  where  the  supposed  vicarious  action  of  other 
organs  is  inadequate  to  perform  the  functions  of  the  extirpated  or 
degenerated  pancreas. 

6.     Obliteration   of   the    Pancreatic    Duct    by   Elastic 
Constriction. 

A  favorite  method  of  studying  the  effect  of  exclusion  of  the 
pancreatic  juice  from  the  digestive  tract  has  been  ligation  of  the  pan- 
creatic duct.  Against  the  reliability  of  these  experiments  it  may 
be  urged  that  in  many  animals  the  pancreas  possesses  more  than  one 
duct,  and  in  some  of  them  accessory  ducts  may  be  present,  which  in 
all  probability  would  be  overlooked  in  the  operation,  and  thus  com- 
plete exclusion  would  not  be  secured.  In  some  of  the  smaller 
animals  even  the  common  duct  is  often  found  only  after  a  prolonged 


EXPERIMENTS   ON   THE  PANCREAS.  315 

and  patient  search,  consequently  any  additional  ducts  or  ductlets 
would  be  very  likely  to  escape  the  attention  of  the  operator.  Babbits 
have,  as  a  rule,  only  one  duct,  which  enters  the  intestine  eight  to  ten 
inches  below  the  pyloric  orifice  of  the  stomach;  on  this  account  the 
results  obtained  by  experiments  of  ligating  the  duct  have  been  most 
reliable  when  this  animal  was  taken  as  a  subject  for  experimentation. 

Amozan  and  Yaillard1  tied  the  pancreatic  duct  in  rabbits,  and 
studied  subsequently  the  histological  changes  in  the  pancreas. 
Animals  that  survived  the  operation,  and  were  killed  after  eight 
days,  were  considerably  emaciated.  On  examining  the  pancreas  it 
was  found,  as  in  the  parotid  gland  after  tying  its  duct,  that  an  exces- 
sive amount  of  connective  tissue  had  formed  in  and  around  the 
lobules,  that  the  ducts  were  much  dilated,  and  the  epithelial  lining 
partly  thrown  off;  the  epithelial  cells  had  changed  in  position  and 
form,  and  appeared  atrophied. 

A  careful  microscopical  examination  of  the  specimen  showed 
that  ligation  of  the  duct  of  Wirsung  produced  a  gradual  transfor- 
mation of  the  pancreas  into  connective  tissue;  the  first  effect  was  an 
enormous  distention  of  the  duct,  which  extended  to  the  most 
remote  portions  of  the  gland.  The  epithelial  cells  became  detached, 
and  with  a  colloid  material  present,  led  to  obstruction  in  the  ducts. 
The  gland  cells,  even  as  early  as  twenty-four  hours  after  ligature, 
became  translucent.  After  a  few  days  the  nuclei  became  swollen, 
and  divided  into  two  or  three  parts,  which  filled  the  interior  of  the 
cell.  After  seven  to  nine  days,  the  place  of  the  cells  was  occupied 
by  free  nuclei  and  round  and  spindle-shaped  cells,  which  were 
transformed  into  connective  tissue.  In  the  neighborhood  of  some 
of  the  veins  collections  of  colorless  corpuscles  could  be  seen.  The 
gland,  on  the  whole,  had  undergone  cirrhotic  atrophy. 

According  to  Charcot  and  Gombault,  the  same  cirrhotic  change 
is  produced  in  the  liver  by  ligating  the  bile-ducts,  while  ligation  of 
the  ducts  of  the  salivary  glands  and  the  ureters  of  the  kidney 
produces  only  slight  or  no  cirrhosis  of  those  organs. 

BSrard  and  Colin'2  ligated  the  pancreatic  duct  in  dogs  which 
had  fasted  for  several  days,  and  then  fed  them  well  for  twenty-four 
hours.     The    animals    cither    showed   no  appetite,  or,  after  eating, 

1  Pancreas  du  Lapin,  Joiirn.  tie  M6d.  de  Bordeaux,  April  8,  1881. 

2  Gazette  hebdomadaire,  vi.  4,  1858. 


316  EXPERIMENTAL  SURGERY. 

ejected  the  food  from  the  stomach.  If  the  animals  were  killed,  the 
lacteals  were  either  only  partially  filled  with  a  milky  fluid,  or,  more 
generally,  they  were  found  empty. 

The  authors  then  tied  the  pancreatic  duct  in  sixteen  dogs 
which  had  fasted  four  or  five  days,  and  immediately  injected  into 
the  duodenum  a  quantity  of  oil  and  lukewarm  water.  The  animals 
were  killed  three  or  four  days  afterward,  and  the  lacteals  were 
found  to  contain  a  white  opaque  chyle  both  in  the  mesentery  and 
walls  of  the  intestine. 

Cohnheim1  claims  that  digestion  is  performed  in  a  remarkably 
satisfactory  manner,  even  in  case  the  pancreatic  juice  is  entirely 
absent,  in  the  intestinal  tract.  He  claims  that  the  presence  of  fatty 
stools  is  the  only  symptom  which  can  be  positively  brought  in 
connection  with  a  defective  or  total  absence  of  pancreatic  secretion. 
He  asserts  that  in  rabbits  it  is  not  difficult  to  ligate  the  pancreatic 
duct,  and  that  in  cases  where  this  was  done,  with  the  exception  of  a 
loss  of  appetite  for  a  few  days,  the  animals  suffered  no  bad  conse- 
quences, and  in  a  few  days  were  as  well  as  before  the  operation. 

Langendorf  ascertained  by  experiment  that  in  pigeons  a  few 
days  after  obliteration  of  the  ducts  of  the  pancreas,  the  desire  for 
food  increased,  but  they  emaciated  progressively,  because,  as  the 
author  asserts,  the  carbohydrates  were  not  digested.  Cohnheim  is 
of  the  opinion  that  in  other  animals  the  capacity  of  other  organs  to 
assume  vicarious  action  is  greater  than  in  birds.  Other  digestive 
fluids  perform  the  function  of  the  pancreas.  The  transformation  of 
starch  into  glucose  is  accomplished  by  the  intestinal  juice,  and  the 
emulsifying  action  of  the  pancreatic  juice  is  assumed  by  the  bile. 
The  remnants  of  undigested  peptones  are  removed  by  way  of  putre- 
faction induced  by  bacteria,  which  are  always  present  in  the 
intestinal  tract. 

That  the  pancreas  continues  to  secrete  after  ligation  of  the 
common  duct,  has  been  demonstrated  in  Heidenhain's  laboratory, 
where,  thirty  days  after  the  duct  had  been  ligated,  normal  pancre- 
atic juice  escaped  through  a  cannula  introduced  into  the  duct.  The 
quantity  was  only  slightly  less  than  from  a  normal  gland,  and  the 
discrepancy  was  readily  explained,  as  some  of  the  gland  structures 
must  have  been  destroyed  by  the  increased  pressure  in  the  duct 

1  Allgemeine  Pathologie,  Berlin,  1882. 


EXPERIMENTS   ON   THE   PANCREAS.  :>>li 

from  the  accumulated  fluid.  As  the  organ  continues  to  secrete,  and 
the  space  for  accumulation  is  limited,  the  only  logical  conclusion 
which  can  he  arrived  at  is  that  the  secretion  is  removed  by  the 
blood-vessels  and  lymphatics  in  the  gland.  It  has  been  shown  by 
Kiihne  that  the  introduction  of  pancreatic  juice  into  the  circulation 
does  not  act  deleteriously,  as  he  injected  one  of  its  most  active 
constituents — trypsin — directly  into  a  vein  without  any  immediate 
or  remote  ill  effect  upon  the  animal.  As  he  detected  this  substance 
in  the  urine,  it  is  reasonable  to  assume  that  the  ferments  of  the 
pancreatic  juice  which  have  not  been  neutralized  by  deoxidation 
into  the  more  innocuous  zymogen  are  eliminated  with  the  renal 
excretions. 

The  following  experiments  were  made,  not  so  much  to  deter- 
mine the  effect  of  ligation  of  the  pancreatic  duct  upon  digestion,  as 
with  a  distinct  purpose  of  studying  the  effects,  in  the  gland  and  its 
duct,  which  would  follow  sudden  obstruction  in  the  duct.  Instead 
of  resorting  to  direct  ligation  of  the  duct,  the  same  object  was 
accomplished  with  greater  certainty  and  more  ease  by  resorting  to 
elastic  constriction  by  using  a  rubber  tube  or  band  which  was  made 
to  include  the  entire  pancreas  with  or  without  its  vessels.  In  every 
instance  the  elastic  constriction  produced  complete  division  of  the 
organ  and  its  duct  in  a  short  time,  and  the  ligature  was  usually 
found  encysted  either  at  the  site  of  application  or  a  little  distance 
from  it. 


Fig.  7.     Normal  microscopic  appearance  of  parenchyma  cells  from 
duodenal  portion. 

Experiment  ]<;.  Adult  black  dog;  weight  thirty  pounds.  Pancreas  and 
duodenum  were  drawn  into  the  abdominal  incision,  and  a  fine  rubber  drainage 
tube  was  passed  between  the  duodenum  and  the  pancreas  at  the  junction  of 
the  middle  with  the  proximal  third,  and  firmly  tied.     The  knot  was  kept  from 


318 


EXPERIMENTAL   SURGERY. 


unfastening  by  transfixion  with  a  silk  ligature.  The  vessels  were  included  in 
the  rubber  ligature.  The  animal  remained  perfectly  well  after  the  operation 
and  gained  three  and  a  half  pounds  in  ten  days.  The  dog  was  killed  forty-nine 
days  after  the  operation.     On  examination  it  was  found  that  the  abdominal 


Fig.  8.     Microscopic  appearance  of  parenchyma  cells  in  isolated 
splenic  portion.     X  500. 

wound  had  healed  completely;  slight  adhesions  between  the  omentum  and  the 
lower  portion  of  the  cicatrix.  The  rubber  ligature  was  found  encysted  at  the 
junction  of  the  middle  with  the  proximal  third   (splenic  end).     The  duodenal 


Fig.  9.     Sclerosis  of  splenic  end.     X  50. 

a.  Lobes  showing  fatty  degeneration.  c.  Artery. 

b.  Connective  tissue.  d.  Vein. 


portion  and  the  distal  portion  of  the  gastrosplenic  end  were  unchanged,  as  the 
secretion  could  enter  the  intestine  through  the  patent  common  duct.  At  the 
point  where  the  ligature  had  been  applied,  the  organ,  with  its  duct,  had  been 


EXPERIMENTS   ON   THE   PANCREAS. 


319 


completely  divided,  the  point  of  section  being  indicated  by  a  contraction  due 
to  cicatrization.  The  duct  in  the  isolated  splenic  portion  was  slightly  dilated; 
parenchymatous  tissue  in  a  state  of  degeneration;  well-marked  sclerosis. 
(Figs.  7,  8,  9.) 

Experiment  Ida.  White  and  yellow  coach  dog,  four  and  a  half  months  old; 
weight  thirty-two  pounds.  In  this  case  the  rubber  ligature  was  applied  about 
the  middle  of  the  gland,  including  the  artery,  but  not  the  vein.  The  animal 
remained  in  excellent  health,  and  was  killed  ninety-eight  days  after  the  opera- 
tion. At  the  autopsy  the  ligature  was  found  encysted  in  a  firm  capsule  about 
the  middle  of  the  gland.  It  had  completely  divided  the  pancreas  and  the 
duct  of  the  splenic  portion  on  the  proximal  side  of  the  common  duct.  The 
duct  in  the  isolated  portion  was  considerably  dilated  throughout,  and  com- 


Fig.  10. 

M.     Point  from  which  microscopical  sections  showing  normal  cells 

were  taken. 
M  .  Point  from  which  microscopical  sections  showing  degenerated 

cells  were  taken. 
a.     Ligature. 

pletely  Obliterated  at  the  point  of  ligation.  This  portion  of  the  gland  had 
undergone  parenchymatous  degeneration  and  sclerosis,  as  the  tissue  was  quite 
firm,  and  grated  on  being  cut  with  the  knife.  The  portion  of  the  gland 
remaining  in  communication  with  the  intestine  through  the  common  duct 
presented  a  normal  appearance. 

Experiment  17.  Adult  black  dog;  weight  twenty  pounds.  Ligation  of  pan- 
creaa  on  the  proximal  side  of  the  common  duct,  excluding  the  artery.  The 
dog   remained   perfectly  well  after   t In-  operation,  gained  considerable   tlesh, 


320 


EXPERIMENTAL  SURGERY. 


and  was  killed  in  four  weeks.  The  rubber  ligature  was  encysted  between  the 
duodenum  and  pancreas.  Complete  division  of  pancreas  and  duct  on  the 
splenic  side  of  the  common  duct.  Slight  dilatation  of  the  duct  in  isolated 
portion,  with  the  same  tissue  changes  as  in  the  preceding  case. 


Fig.  11.     Section  taken  from    M,  splenic   portion,  showing  normal 
parenchyma.     X  500. 


Fig.    12.       Incomplete    fatty    degeneration,  from   duodenal  portion 
of   gland.     X  500. 

Experiment  18.  Adult  black  cat;  weight  five  and  a  half  pounds.  The 
pancreas  was  detached  from  the  duodenum  to  the  extent  of  three-quarters  of 
an  inch,  and  the  rubber  ligature  applied  so  as  to  exclude  the  artery.  On  the 
second  day  the  temperature  rose  to  106°  F.,  but  the  general  condition  of  the 
animal  was  undisturbed.  The  fever  soon  subsided,  and  digestion  and  nutrition 
were  at  no  time  impaired.      The  cat  was  killed  thirty-eight  days  after  opera- 


EXPERIMENTS   ON    THE   PANCREAS.  321 

tion.  The  ligature  was  found  encysted  between  (he  pancreas  and  duodenum 
on  the  distal  side  of  the  common  duct.  Complete  division  of  the  pancreas 
and  obliteration  of  the  duct  Tby  a  linear  cicatrix.  The  detached  mesentery 
was  united  with  the  bowel.  The  detached  duodenal  portion  of  gland  had 
almost  disappeared  by  absorption,  only  connective  tissue  and  vessels  being 
left  to  indicate  the  contour  of  the  gland.     (Figs.  10,  11,  12,  13.) 


Fig.  13.     Complete   fatty    degeneration,  from   duodenal    portion  of 
gland,      a.     Artery. 

Experiment  1!>.  Adult  white  cat;  weight  six  and  a  half  pounds.  Detached 
pancreas  and  vessels  from  duodenum  to  the  extent  of  an  inch  and  a  half,  and 
applied  a  rubber  ligature  about  the  middle  of  the  gland,  including  the  vessels. 
Next  day  the  temperature  was  105°  F.;  later,  normal.  No  disturbance  of 
digestion  or  nutrition.  The  cat  was  killed  eighty-five  days  after  operation. 
The  rubber  ligature  was  encysted  between  duodenum  and  pancreas  on  distal 
side  of  the  common  duct.  Complete  section  of  pancreas  and  obliteration  of 
duct.  The  duodenal  portion,  had  almost  completely  disappeared  by  absorp- 
tion; the  connective  tissue  of  the  gland,  the  dilated  ducts,  and  the  abundant 
vascular  supply,  served  to  indicate  the  outlines  of  the  atrophied  portion. 
Mesentery  of  the  duodenum  was  perfect.     (Fig.  14.) 

Experiment  20.  Young  black  cat;  weight  two  pounds.  Isolated  pancreas 
to  the  extent  of  two  inches  from  intestine,  and  included  the  detached  portion 
between  two  silk  ligatures,  firmly  tied.  Temperature  was  high  on  second  and 
sixth  days.  Animal  died  on  sixth  day.  Abdominal  wound  was  firmly  united. 
On  opening  the  abdominal  cavity  no  effusion  was  found.  No  general  perito- 
nitis. Abscess  between  duodenum  and  liver;  ligated  portion  detached,  gan- 
grenous; ligatures  not  encysted.  Abscess  in  communication  with  pancreas. 
Acute  atrophy  of  the  entire  pancreas.  No  gangrene  of  duodenum.  In  this 
case  the  suppurative  process  started  from  the  portion  of  pancreas  which  had 
been  included  between  the  ligatures.  We  shall  find  that  when  infection  does 
not  take  place,  even  isolated  <l<  ad  pancreatic  tissue  is  amenable  to  absorption. 

Experiment  .'/.  Old  cat;  weight  four  pounds.  Detached  gastrosplenio 
portion  of  the  pancreas  to  tin  extent  of  an  inch  and  a  half  from  duodenum, 
and   applied  two  rubber  ligaturee  about  half  an  inch  apart,  including     the 

'21 


322 


EXPERIMENTAL   SURGERY. 


vessels.  On  the  following  day  the  cat  was  quite  ill,  without  any  rise  in  tem- 
perature. For  several  days  vomiting  was  the  most  prominent  symptom.  The 
animal  died  on  the  sixth  day.  Abdominal  wound  united;  no  peritonitis;  no 
effusion.  Pancreas  adherent  to  transverse  colon;  on  separating  the  adhesion 
a  small  cyst  containing  about  three  drachms  of  a  clear,  transparent  fluid  was 
ruptured.  As  this  cyst  corresponded  to  the  place  where  the  ligatures  had 
been  applied,  it  was  undoubtedly  a  collection  of  pancreatic  juice  which 
had  escaped  from  the  divided  duct,  and  around  which  a  connective  tissue  wall 
had  formed.  The  ligatures  had  cut  through  the  organ  and  duct.  The  ends 
of  the  gland  had  retracted.  Duodenum  healthy.  Mesenteric  detachment  not 
repaired.     No  suppuration  anywhere. 


Fig.  14. 
a.  Ligature. 

M.  Portion    taken   for   microscopical   examination   which   showed 
complete  absence  of  parenchyma  cells. 


Experiment  22.  Adult  dog;  weight  thirty-nine  pounds.  Detached  the 
pancreas,  about  its  middle,  from  duodenum,  to  the  extent  of  two  inches,  and 
applied  two  rubber  ligatures,  about  one  inch  apart,  including  the  vessels.  On 
the  following  day  the  dog  appeared  quite  sick.  Increase  of  temperature  after 
sixth  day;  no  appetite,  and  rapid  emaciation.  On  the  ninth  day,  diarrhoea, 
which  became  later  dysenteric  in  character.  Died  on  the  nineteenth  day, 
having  lost  during  this  time  six  and  a  half  pounds  in  weight.  Abdominal 
wound  completely  united.  No  general  peritonitis.  Pancreas  and  duodenum 
adherent  to  liver.  Portion  of  pancreas  between  ligatures  gangrenous — con- 
tained in  an  abscess  cavity.      Ligatures  detached  and  loose  in  abscess  cavity. 

Experiment  23.  Adult  black  dog;  weight  twenty  pounds.  Inclusion  of 
two  inches  of  the  pancreas  and  its  vessels,  after  separation  from  duodenum, 
between  two  silk  ligatures  about  the  center  of  the  gland.  The  dog  was  very 
sick  on  second  day,  and  thermometer  showed  an  increase  of  temperature  to 
104.4    F.,  which  continued  with  slight  variations  until  the  animal  died  on  the 


EXPERIMENTS   ON   THE  PANCREAS. 


323 


sixth  day.  Wound  completely  united.  Diffuse  purutent  peritonitis,  and 
extensive  adhesions.  Ligated  portion  gangrenous  and  loose,  with  ligatures 
in  abscess  cavity  between  duodenum  and  pancreas. 

Experiment  24.  Adult  gray  cat;  weight  five  and  three  quarters  pounds. 
Isolated  pancreas  and  vessels  from  duodenum  to  the  extent  of  an  inch  and  a 
half,  and  included  this  portion  between  two  ligatures.  Animal  remained  well 
for  four  days,  when  symptoms  of  peritonitis  appeared.  Died  on  tenth  day. 
Wound  nicely  united.  No  peritoneal  effusion.  Localized  peritonitis  at  site 
of  operation.  Ligatures  and  ligated  section  of  pancreas  loose  in  abscess 
between  the  duodenum  and  pancreas.  Pancreatic  veins  thrombosed.  Duct 
of  splenic  portion  in  direct  communication  with  the  abscess  cavity. 

Experiment  25.  Adult  cat;  weight  six  pounds.  Pancreas  with  its  vessels 
detached  from  duodenum  to  the  extent  of  two  inches,  and  this  portion  included 
between  two  ligatures.  On  fifth  day  temperature  106°  F.,  gradual  decrease 
subsequently  to  normal.     For  a  number  of   days  during    the  febrile  attack, 


Fig.  15. 

a.  Ligatures. 

b.  Duodenal  portion  atrophied  and  undergoing  fatty  degeneration. 

c.  Dilated  duct. 


complete  loss  of  appetite.  After  this,  appetite  and  nutrition  were  good. 
Killed  twenty-eight  days  after  operation.  Portion  of  gland  between  ligatures 
completely  disappeared  by  absorption.  Ligatures  in  close  proximity  and 
encysted  in  firm  capsule.  Duodenal  end  atrophied,  in  which  the  dilated  duct 
was  distinctly  visible.     Splenic  end  somewhat  atrophied.     (Fig.  16.) 

Experiment  26.  Large  Newfoundland  dog;  weight  fifty-five  pounds. 
Rubber  ligatures  made  to  include  one  inch  of  the  pancreas  about  its  middle, 
with  exclusion  of  its  vessels.  Slight  fever  on  third  day,  subsequently  no 
Symptoms    indicating    disturbance   of   digestion   or   disease.     Animal    killed 


324 


EXPERIMENTAL  SURGERY. 


thirty-one  days  after  operation.  Intervening  portion  of  pancreas  disappeared 
by  absorption.  Ligatures  encysted.  Loss  of  substance  replaced  by  bridge  of 
connective  tissue.  Duodenal  end  atrophic,  with  dilated  duct.  Gastrosplenic 
portion  normal  in  appearance,  and  in  direct  communication  with  the  intes- 
tine through  the  common  pancreatic  duct. 

Remarks. — Only  two  of  the  animals  recovered  after  isolation 
and  double  ligation  of  the  pancreas,  a  fact  which  shows  the  great 
danger  of  leaving  pancreatic  tissue  not  supplied  with  blood  in  the 
abdominal  cavity.  We  can  only  assume  that  the  danger  of  infection 
is  increased  by  leaving  an  exceedingly  favorable  culture  substance 
for  infective  germs  in  the  abdomen.  If  the  operation  is  perfectly 
aseptic,  the  dead  pancreatic  tissue  remains  aseptic,  and  is  removed 
in  an  exceedingly  short  time  by  absorption. 


X  d  \ 


Fig.  16.     Posterior  view. 

a.  Common  duct. 

b.  Ligature. 

c.  Duodenal    portion,  atrophy  and  fatty    degeneration   marked, 

duct  dilated. 

d.  Liver,  pancreas  adherent  to. 

Experiment  27.  Large  adult  cat.  Applied  a  single  rubber  ligature  on 
distal  side  of  the  common  pancreatic  duct,  excluding  the  artery  and  vein.  No 
disturbance  of  digestion  or  nutrition,  and  temperature  normal  throughout. 
Animal,  when  killed  twenty-eight  days  after  operation,  had  grown  fat.  Only 
a  few  slight  adhesions  at  site  of  ligation.  Pancreas  and  duct  were  completely 
divided  by  the  ligature,  the  ends  kept  in  contact  by  a  linear  cicatrix.     Liga- 


EXPERIMENTS   ON   THE   PANCREAS. 


325 


tare  was  encysted  between  the  duodenum  and  under  surface  of  the  liver.  The 
gastrosplenic  portion  of  the  pancreas  was  normal  in  appearance,  and  con- 
nected with  the  common  duct.  The  duodenal  portion  was  atrophied;  the  duct 
slightly  dilated.     (Fig.  16.) 

Experiment  28.  Large  Newfoundland  dog.  Ligation  of  the  pancreas  and 
its  vessels  with  a  rubber  ligature  on  the  proximal  side  of  the  common  duct. 
No  fever,  no  disturbance  of  digestion  or  nutrition.  Animal  was  killed  ninety - 
one  days  after  operation.  On  opening  the  abdominal  cavity,  the  entire  pan- 
creas presented  a  normal  appearance  in  size,  shape  and  consistence.  Where 
the  ligature  was  applied  a  narrow  constriction  was  visible,  which  represented 


Fig.  17. 

a.  Duct  of  Wirsung. 

b.  Ductus  choledochus. 

c.  Main  pancreatic  ducts. 

d.  Ligature. 

e.  Accessory  duct. 

fche  point  of  section  made  by  the  ligature.  Ligature  was  encysted  in  the 
cicatrix.  On  tracing  the  pancreatic  duct  from  the  interior  of  fche  Lntestine,  a 
probe  could  be  passed  along  the  duct  of  the  duodenal  portion.  On  following 
the  duct  of  the  splenic  portion,  the  probe  was  arrested  at  the  cicatrix,  about 
a  quarter  Of  an  inch  from  fche  wall  Of   the  intestine.       The  duct  at    this    point 

was  complete!;  obliterated. 


326  EXPERIMENTAL  SURGERY. 

As  in  all  of  the  previous  experiments  the  detached  portion  of  the  gland 
had  invariably  become  the  seat  of  degenerative  changes  and  atrophy,  I  was  at 
a  loss  to  account  for  the  normal  appearance  of  the  gastrosplenic  portion  of  the 
gland  in  this  instance.  After  a  prolonged  and  careful  search  a  minute  open- 
ing was  detected  in  the  fold  of  the  mucous  membrane  surrounding  the  outlet 
of  the  bile-duct,  and  by  careful  manipulation  a  delicate  probe  was  passed 
along  a  canal  which  passed  obliquely  through  the  wall  of  the  bowel,  entered 
the  pancreas  on  the  splenic  side  of  the  ligature,  and  terminated  in  the  large 
duct  of  the  gastrosplenic  portion.     (Fig.  17.) 

The  explanation  for  the  absence  of  atrophic  changes  had  been  found.  An 
accessory  duct  had  furnished  an  outlet  for  the  secretion  in  the  gastrosplenic 
portion,  and  had  maintained  the  physiological  connection  between  this  portion 
of  the  gland  and  the  duodenum  after  obliteration  of  the  common  duct  of  the 
gastrosplenic  portion.  It  was  the  only  instance  where  such  a  structure  was 
detected,  and  the  only  specimen  in  which  the  normal  structure  of  the  detached 
portion  of  the  gland  was  preserved  after  obliteration  of  the  principal  duct. 

Remarks. — These  experiments  illustrate  the  feasibility  of  liga- 
tion of  either  portion  of  the  pancreas  near  the  common  duct  as  a 
surgical  procedure,  and  the  regularity  with  which  the  pancreatic 
tissue  is  removed  by  degeneration  and  absorption  in  the  detached 
portion  of  the  gland.  By  physiological  detachment,  I  mean  a  per- 
manent interruption  to  the  escape  of  secretion,  by  section  or  oblitera- 
tion of  the  duct. 

After  ligation  of  the  duct  or  gland,  secretion  continues,  and  as 
the  space  for  accumulation  of  the  fluid  is  limited,  a  certain  degree  of 
pressure  within  the  duct  is  established,  as  is  evident  from  the  uni- 
formity with  which  the  ducts  throughout  that  portion  of  the  gland 
were  found  dilated.  In  no  instance,  however,  was  anything  observed 
which  resembled  a  cyst.  The  dilatation  was  not  limited  to  any  par- 
ticular portion  of  the  duct,  it  always  presented  itself  as  a  uniform 
ectasia  of  the  entire  duct.  We  can  only  explain  the  moderate  dila- 
tation by  assuming  that,  as  soon  as  a  certain  degree  of  pressure  is 
reached,  the  pancreatic  juice  is  removed  by  the  vessels  and  lymphat- 
ics of  the  pancreas,  by  absorption,  and  that  a  greater  accumulation 
of  fluid  and  distention  of  the  duct  could  only  occur  when  this  func- 
tion has  become  diminished  or  suspended  by  organic  changes  in  the 
structures  which  are  concerned  in  the  removal  of  the  secretion.  The 
atrophic  changes  in  the  parenchyma  of  the  detached  portion  of  the 
gland  have  been  ascribed  to  the  pressure  within  the  ducts  upon  the 
parenchyma  cells — a  sort  of  pressure  atrophy. 

This  supposition  lacks  proof,  inasmuch  as  the  pressure  at  any 


EXPERIMENTS   ON   THE   PANCREAS.  327 

time  could  not  have  been  considerable,  and  as  the  same  atrophic 
changes  have  been  observed  in  cases  where  no  pressure  could  have 
existed,  as  in  cases  of  external  and  internal  pancreatic  fistula,  where 
the  duct  remains  open  until  secretion  ceases.  The  atrophy  can  also 
not  be  due  to  deficiency  of  blood  supply,  as  it  occurred  regularly  and 
as  rapidly  in  cases  where  the  blood  supply  remained  unimpaired; 
and  in  many  of  the  specimens,  illustrating  complete  atrophy,  the 
abundant  vascular  supply  was  distinctly  observed  and  noted.  I  am 
unable  to  furnish  a  satisfactoiy  explanation  of  the  cause  of  this 
form  of  atrophy.  All  that  I  can  say  is,  that  in  every  instance  in 
which  complete  physiological  detachment  had  been  produced  by  liga- 
tion, resection,  crushing,  or  any  other  means,  this  result  followed 
without  exception. 

Practically  this  observation  is  of  great  importance,  because  it 
demonstrates  that  in  operations  upon  the  pancreas  it  is  not  essential 
or  necessary  to  remove  peripheral  portions  of  the  gland,  for  fear 
that  if  any  of  the  parenchymatous  structure  should  remain  a  reten- 
tion cyst  would  follow.  In  partial  resections  for  injury  or  disease 
it  would  be  advisable  to  ligate  the  peripheral  portion,  and  permit 
it  to  remain,  as  it  would  lessen  the  danger  by  the  infliction  of  less 
traumatism,  and  as  we  can  confidently  expect  that  it  will  be  removed 
in  a  short  time  by  absorption. 

These  experiments  settle  definitely  an  important  pathological 
question.  It  has  been  claimed  by  all  writers  that  cysts  of  the  pan- 
creas are  produced  by  obstruction  of  the  common  duct.  In  most  of 
the  specimens  which  have  been  examined,  it  is  distinctly  stated  that 
the  obstruction  was  not  complete,  as,  for  instance,  in  cases  of  impac- 
tion of  pancreatic  calculi  when  found  in  connection  with  cysts.  In 
all  of  these  experiments  obstruction  of  the  duct  was  sudden  and 
complete  by  the  elastic  constriction,  and  subsequently  permanent  by 
the  formation  of  a  cicatrix  between  the  divided  ends  of  the  duct. 

In  none  of  the  specimens,  where  life  was  sufficiently  prolonged, 
did  the  process  of  obliteration  fail  to  take  place,  and  yet  in  none  of 
them  was  even  an  attempt  at  the  formation  of  a  cyst  observed. 

The  experiments  with  the  double  ligature  teach  the  importance 
of  removing  such  portion-,  of  the  pancreas  as  are  not  supplied  with 
blood-vessels,  rather  than  trusting  to  the  doubtful  expedient  of  leav- 
ing  them  to  he  removed   by  absorption;   as  dead  pancreatic  tissue  is 


328  EXPERIMENTAL  SURGERY. 

an  exceedingly  putrescible  substance,  and  furnishes  the  most  favor- 
able conditions  for  the  growth  and  increase  of  septic  germs. 

7.     External  Pancreatic  Fistula. 

The  formation  of  a  permanent  pancreatic  fistula  has  always 
constituted  one  of  the  most  difficult  tasks  in  experimental  physiology. 
Bernard,1  after  many  fruitless  attempts,  declared  that  it  was  impos- 
sible to  establish  a  permanent  pancreatic  fistula,  for  the  reason  that 
the  cannula  invariably  fell  out  after  a  few  days,  after  which  the  duct 
again  conveyed  its  contents  into  the  duodenum.  He  found,  also, 
that  the  pancreatic  juice  which  flowed  from  the  fistula  remained 
normal  for  only  twelve  or  sixteen  hours,  after  which  time  it  became 
thinner,  and  did  not  coagulate  on  the  application  of  heat.  Neither 
did  it  possess  any  longer  the  property  of  decomposing  fat  into 
glycerine  and  fatty  acids.  This  change  in  the  pancreatic  juice 
always  appeared  as  soon  as  inflammation  was  noticed  about  the  seat 
of  operation.  In  horses  and  cattle  this  condition  appeared  so  early, 
that  it  was  found  impossible  to  obtain  pure  pancreatic  juice  from  a 
fistula. 

The  intermittent  action  of  the  pancreas  is  well  illustrated  in 
animals  when  a  fistula  has  been  established,  active  secretion  taking 
place  only  during  digestion.  Bernard  ascertained  that  in  medium- 
sized  dogs  not  more  than  five  or  six  grammes  of  juice  could  be 
obtained  in  an  hour.  Ether  injected  into  the  stomach  increased 
the  secretion,  while  vomiting  suspended  the  flow  of  fluid,  but  not  its 
secretion,  since  just  after  the  act  it  was  poured  out  in  so  much  greater 
quantities.  Pressure  on  the  abdomen  and  the  respiratory  movement 
of  the  chest  accelerated  the  flow  from  the  fistula. 

The  following  experiments  were  made  for  the  distinct  purpose 
of  studying  the  functional  'activity  of  a  detached  portion  of  the  pan- 
creas, consequently  a  different  method  of  operating  had  to  be 
devised.  Having  satisfied  myself  that  physiological  detachment  of 
a  portion  of  the  pancreas  by  section,  resection,  or  ligation  always 
results  in  degeneration  of  the  parenchyma,  and  atrophy  of  the 
detached  portion,  I  determined  to  study  this  subject  more  thoroughly 
by  interrupting  all  anatomical  continuity  between  the  detached 
and  the  principal  portion  of  the  gland. 

1  Legons  de  physiol.  exper.  appliqu6e  &  la  medecine,  t.  ii.,  Paris,  1855. 


EXPERIMENTS   ON   THE   PANCREAS.  329 

An  external  pancreatic  fistula  was  established  by  bringing  the 
pancreas  with  the  duodenum  into  the  wound,  ligating  the  pancreas 
usually  below  the  common  duct,  dividing  the  gland  and  its  vessels 
completely  on  the  distal  side  of  the  ligature,  arresting  carefully  the 
hemorrhage  from  the  cut  surface  without  interfering  with  the  prin- 
cipal duct,  detaching  the  distal,  or  duodenal  portion  sufficiently  from 
the  bowel,  so  as  to  bring  the  cut  surface  a  little  above  the  level  of 
the  outer  surface  of  the  wound,  where  it  was  fixed  with  four  catgut 
sutures  to  the  margins  of  the  wound.  The  remaining  portion  of  the 
wound  was  closed  in  the  visual  manner.  This  method  secured  a  per- 
manent pancreatic  fistula,  the  outflow  from  which  would  indicate  the 
amount  of  secretion  from  the  detached  portion  of  the  gland. 

Experiment  29.  Young  dog;  weight  thirty  pounds.  Ligation  of  pancreas 
at  junction  of  middle  with  distal  portion,  section  of  gland  immediately  below 
ligature,  separation  of  detached  portion  from  duodenum  to  the  extent  of  two 
inches,  implantation  of  free  end  into  the  lower  angle  of  the  abdominal  incision 
with  four  catgut  sutures.  During  the  second  day,  slight  rise  in  temperature. 
During  the  first  day  the  dog  refused  to  eat,  and  no  pancreatic  juice  was  seen 
to  escape  from  the  cut  surface  of  the  gland.  The  second  day  the  secretion 
was  copious,  resembling  normal  pancreatic  juice.  The  discharge  was  inter- 
mittent, most  copious  a  few  hours  after  eating,  and  entirely  absent  when  the 
animal  fasted.  At  the  end  of  the  first  week,  the  secretion  became  less  in 
quantity,  and  gradually  continued  to  decrease  until  it  ceased  entirely  on  the 
twenty-first  day.  The  portion  of  the  pancreas  included  in  the  wound  became 
smaller  from  day  to  day,  and  appeared  to  have  disappeared  almost  entirely 
when  the  secretion  ceased,  leaving  at  this  place  an  irregular  depressed  cica- 
trix, with  no  tendency  to  hernial  protrusion.  The  animal  remained  in  per- 
fect health  and  was  killed  seventy  days  after  operation. 

At  the  autopsy,  the  cut  end  of  the  atrophic  duodenal  portion  of  the  pan- 
creas was  found  adherent  to,  and  incorporated  in  the  firm  cicatrix  of  the 
abdominal  wound.  The  parenchyma  in  the  detached  portion  of  the  gland  had 
disappeared  completely;  in  the  center  of  this  portion  the  principal  duct  could 
be  seen  dilated  to  the  size  of  a  lead-pencil,  and  containing  a  clear,  transparent 
fluid.  The  duct  could  be  traced  to  the  peripheral  extremity  of  the  gland  in 
one  direction,  and  into  the  cicatrix  of  the  abdominal  wound  in  t  he  other.  The 
atrophic  portion  of  the  gland  was  freely  supplied  with  blood-vessels.  The 
duct  was  widest  near  the  cicatrix,  and  gradually  tapered  toward  the  end  of  the 
gland.  The  cut  proximal  end  had  become  adherent  to  the  duodenum.  A 
probe  could  be  passed  from  the  duodenal  end  of  the  common  pancreatic  duct 
along  the  entire  distance  of  the  splenic  portion;  the  point  of  section  had 
evidently  been  made  on  the  peripheral  side  of  the  common  ilnet.  through  the 
duodenal  portion  of  the  gland.     (Fig.  L8.) 

Experiment  30.  Adult  eat:  weight  live  pounds.  In  this  case  the  gland 
livide lar  the  middle.     The  duodenal   portion  was  detached  from  the 


330 


EXPERIMENTAL  SURGERY. 


intestine  to  the  extent  of  two  inches,  and  sewed  into  the  lower  angle  of  the 
incision.  Second  day,  temperature,  108.5°  F.  The  animal  took  but  little  food, 
and  only  a  very  small  amount  of  secretion  was  observed  to  escape  from  the 
duct  on  the  cut  surface  of  the  gland.  The  cat  died  on  the  third  day,  after  the 
temperature  had  shown  an  increase  to  106°  F.  At  the  autopsy  it  was  shown 
that  death  had  resulted  from  purulent  peritonitis,  and  croupous  pneumonia  of 
right  lung.     No  gangrene  of  duodenum  or  pancreas. 


Fig.  18. 

a.  Point  of  division  of  gland. 

b.  Portion  of   gland  planted  into  wound,  showing  complete 

atrophy. 

c.  External  cicatrix. 

d.  Dilated  duct. 

M.  Portion  taken  for  microscopical  sections,  showing  normal 
structure  of  gland. 

Experiment  31.  Adult  cat;  weight  five  and  three-fourths  pounds.  Opera- 
tion same  as  before.  The  animal  was  quite  ill  for  three  days;  at  the  end  of 
this  time  the  temperature  was  104.8°  F.;  took  but  little  nourishment.  From 
this  time  improvement  took  place,  and  finally  complete  recovery.  Escape  of 
pancreatic  juice  was  first  observed  on  second  day;  it  gradually  increased  for 
three  days,  when  it  began  to  diminish  and  ceased  completely  on  the  seven- 
teenth day,  when  the  wound  closed  completely,  showing  no  tendency  to  ventral 
hernia.     Unfortunately  the  animal  was  lost  on  the.forty-eighth  day. 


EXPERIMENTS   OX   THE   PAXCREAS. 


831 


Experiment  32.  Black  shepherd  dog;  weight  forty-three  and  a  half 
pounds.  Ligation  of  pancreas  about  its  middle,  double  ligation  of  pan- 
creatico-duodenal  artery,  division  of  gland,  application  of  four  ligatures  to 
arrest  haemorrhage  from  the  distal  portion  of  the  gland,  detachment  of 
duodenal  end  to  the  extent  of  two  inches  from  intestine,  and  fixation  of  free 
end  into  the  lower  angle  of  the  incision  by  four  catgut  sutures.    No  untoward 


Fig  19.     External  pancreatic  fistula. 

s.  Portion  of  skin  with  external  cicatrix  in  center. 
d.  Dilated  duct. 
M.  Portion  taken  for  microscopical  examination,  showing  advanced 

fatty  degeneration  of    parenchyma,  and  sclerosis  throughout 

entire  transplanted  portion  of  gland. 


Fig.  20.     External  pancreatic  fistula,  from  duodenal  portion  of  gland. 

Some  of  the  acini  completely  empty,  others  show  groups  ot  cells  in 
advanced  stage  of  fatty  degeneration. 


symptoms  after  operation.  Free  escape  of  pancreatic  juice  at  the  end  til  the 
second  day,  which  continued  quite  profuse  for  ten  days  during  digestion,  when 
it  began  to  diminish,  and  ceased  entirely  on  the  twenty-fifth  day  after  the 
Operation.  During  the  first  six  days  the  animal  lost  four  pounds  in  weight, 
after   fchia   time  digestion  and  nutrition  were    perfect.       The  dog  was    killed 


332  EXPERIMENTAL  SURGERY. 

forty-six  days  after  operation.  Post-mortem  appearance  was  almost  identical 
with  that  in  experiment  29,  except  that  the  duodenum  was  found  adherent  to  the 
under  surface  of  the  liver.  The  vascularity  of  the  atrophic  duodenal  end  was 
particularly  well  marked.     (Figs.  19,  20.) 

Remarks. — These  experiments  have-  demonstrated  conclusively 
that  when  a  portion  of  the  pancreas  is  detached  by  complete  section, 
secretion  continues  until,  by  degeneration  and  absorption,  the  paren- 
chyma of  the  gland  has  disappeared.  The  degeneration  evidently 
commences  at  the  end  of  eight  to  twelve  days,  and  progresses 
rapidly  and  continuously  until  the  end  of  twenty  to  twenty- seven 
days,  when  all  of  the  secreting  structures  have  lost  their  physio- 
logical function,  as  indicated  by  a  permanent  cessation  of  the  flow 
of  pancreatic  juice.  The  existence  of  distention  of  the  principal 
duct  in  these  cases  can  only  be  explained  by  assuming  that  it  occurs 
after  closure  of  the  fistula  has  taken  place  by  an  accumulation  of  secre- 
tion from  the  lining  of  the  duct,  or  that  the  dilatation  is  caused  by 
traction  upon  the  outer  surface  of  the  duct  by  the  connective  tissue 
framework  of  the  gland,  or  the  contraction  incident  to  interstitial 
connective  tissue  proliferation. 

That  the  atrophy  in  the  part  of  the  organ  which  had  been 
detached  from  its  connections  with  the  intestine  was  not  due  to  a 
traumatic  interstitial  pancreatitis  is  proved  by  the  normal  appearance 
and  structure  of  the  remaining  portion  of  the  gland  which  had 
retained  its  anatomical  and  physiological  relations  to  the  intestine. 
I  am,  therefore,  again  supported  in  the  assertion  that  physiological 
detachment  of  any  portion  of  the  pancreas  is  invariably  followed  by 
degeneration  and  complete  atrophy,  consequently  also  by  complete 
cessation  of  functional  activity. 

8.     Internal  Pancreatic  Fistula. 

It  is  a  well-known  fact  that  when  pancreatic  juice  is  brought  in 
contact  with  the  skin  it  produces  irritation,  an  effect  which  has  been 
attributed  to  its  digestive  qualities.  In  all  the  animals  where  an 
external  pancreatic  fistula  was  established,  the  skin  appeared  sore 
and  macerated  as  far  as  it  had  been  kept  moist  with  the  pancreatic 
juice. 

Clinical  observation  has  shown  that  in  nearly  all  cases  where  a 
cyst  of  the  pancreas  was  treated  by  the  formation  of  a  pancreatic 
fistula,  the  skin  around  the  fistula  remained  in  an  eczematous  condi- 


EXPERIMENTS   ON   THE   PANCREAS.  333 

tion  so  long  as  the  fistula  continued  to  discharge  fluid.  Taking 
these  facts  into  consideration,  we  should  naturally  anticipate  that 
when  pancreatic  juice  is  brought  in  contact  with  the  peritoneum  it 
will  produce  a  destructive  effect  upon  it  by  its  digestive  properties, 
or  that  it  may  be  even  followed  by  diffuse  peritonitis. 

In  opposition  to  this  reasoning,  Bernard  informs  us  that  none 
of  his  animals  died  when  he  had  made  a  pancreatic  fistula,  and  as  in 
these  cases  extravasation  of  pancreatic  juice  into  the  peritoneal 
cavity  was  almost  inevitable,  it  would  appear  that  its  effects  here  are 
not  so  disastrous  as  when  it  acts  upon  the  skin. 

Concerning  this  point,  Heidenhain  remarks:  "The  animals  do 
not  suffer  from  this  circumstance,  as  the  duct  is  regenerated  in  spite 
of  the  wounded  surface  being  bathed  in  the  secretion.  Nevertheless, 
it  is  difficult  to  explain  this.  Why  do  not  the  wounded  and  suppu- 
rating tissues  undergo  digestion  by  the  pancreatic  juice?  The 
efficacy  of  the  albumen  ferment  is  destroyed  in  some  way,  I  presume, 
probably  by  being  converted  into  zymogen,  the  living  tissues  having 
the  effect  on  the  juice  as  Podolinski  observed,  by  treating  the  pan- 
creatic juice  with  powdered  zinc  or  yeast  ferment." 

As  pancreatic  juice,  when  brought  in  contact  with  the  atmos- 
pheric air,  may  undergo  rapid  changes,  and  thus  be  rendered  abnor- 
mal, experiments  made  with  it  by  injecting  it  into  the  peritoneal 
cavity  would  not  represent  the  action  of  normal  pancreatic  juice 
upon  the  peritoneum,  hence  the  results  obtained  would  not  represent 
the  effects  of  normal  secretion. 

To  determine  the  effect  of  normal  pancreatic  juice  on  the 
peritoneum,  I  resorted  to  the  formation  of  an  internal  pancreatic 
fistula,  so  as  to  bring  the  peritoneum  in  contact  with  the  normal 
pancreatic  secretion  as  it  escaped  from  the  cut  surface  of  the  gland. 
My  experiments  with  external  pancreatic  fistula  had  taught  me  that 
the  isolated  portion  of  the  gland  continued  to  secrete  for  seventeen 
to  twenty-six  days;  hence,  I  was  convinced  that  if  I  could  establish 
the  same  conditions  within  the  peritoneal  cavity,  I  would  secure  an 
intermittent  flow  of  normal  pancreatic  juice  into  the  peritoneal  eavit\ 
for  the  same  length  of  time.  The  operation  was  performed  in 
precisely  the  same  manner  as  for  external  fistula,  except  that  the  oul 
end  of  the  duodenal  portion  was  detached  from  the  duodenum, 
turned  downward,  and  dropped  into  the  peritoneal  cavity. 


334  EXPERIMENTAL  SURGERY. 

Experiment  33.  Young  dog;  weight  thirty-one  and  a  half  pounds. 
Divided  the  pancreas  near  middle,  detached  duodenal  end  from  bowel  to  the 
extent  of  three  inches,  turned  it  downward,  and  closed  the  abdominal  wound 
completely.  Second  day,  temperature  106°  F.;  slight  tympanites.  Dog 
appeared  quite  ill  for  a  number  of  days,  and  temperature  remained  above 
normal  for  a  week,  although  the  animal  remained  in  good  condition  until 
killed,  seventy-six  days  after  the  operation.  The  autopsy  showed  evidences 
of  a  former  local  peritonitis  at  the  site  of  operation;  the  duodenal  or 
detached  end  of  pancreas  was  completely  atrophied,  its  ducts  dilated,  closed, 
and  adherent  to  duodenum.  Splenic  portion  normal  in  site  and  appearance; 
cut  end  adherent  to  duodenum;  common  duct  pervious. 

Experiment  34.  Adult  dog;  weight  twenty-one  pounds.  Detached  pan- 
creas from  its  middle  toward  distal  side  to  the  extent  of  five  inches.  Divided 
the  pancreas  with  Paquelin's  cautery,  between  two  compression  forceps;  used 
no  ligatures.  Turned  end  of  lower  portion  downward,  and  closed  the  abdom- 
inal incision.  Animal  died  on  the  third  day,  with  symptoms  of  peritonitis. 
No  rise  in  temperature.  Post-mortem  examination  showed  evidences  of 
diffuse  purulent  peritonitis;  no  haemorrhage,  no  sign  of  gangrene  of  duo- 
denum. 

Experiment  35.  Adult  dog;  weight  thirty-seven  pounds.  Ligated  pan- 
creas on  distal  side  of  common  duct.  Divided  the  gland  transversely  just 
below  ligature,  tied  vessels  with  catgut,  detached  duodenal  portion  from 
intestine  to  the  extent  of  three  inches,  turned  the  free  end  downward,  and 
closed  the  abdominal  incision.  Temperature  remained  normal,  but  the 
animal  was  reported  sick  for  five  days,  when  recovery  set  in,  and  the  dog 
remained  in  good  health  as  long  as  he  was  under  observation — thirty-two  days, 
when  he  ran  away. 

ExperimeMt  36.  Adult  cat;  weight  five  and  a  quarter  pounds.  Applied 
ligature  below  common  pancreatic  duct,  and  divided  the  gland  on  distal  side 
of  ligature,  detached  duodenal  portion  from  intestine  to  the  extent  of  two 
inches,  turned  the  free  end  downward,  and  closed  the  abdominal  wound.  The 
animal  remained  well  after  the  operation,  and  was  in  good  condition  when 
killed  eighty-three  days  after  the  operation.  Great  omentum  was  adherent  to 
lower  border  of  liver;  mesentery  adherent  to  duodenum;  duodenal  portion  of 
gland  completely  atrophied;  cut  extremity  of  splenic  portion  adherent  to 
duodenum  by  a  firm  cicatrix  just  below  the  entrance  of  the  common  duct 
into  the  intestine.  This  portion  of  the  gland  was  normal  in  size  and  appear- 
ance.    Atrophied  portion  was  abundantly  supplied  with  blood-vessels. 

Experiment  37.  Adult  cat;  weight  five  and  a  half  pounds.  Pancreas 
was  ligated  just  below  the  common  duct,  transverse  section  of  the  pancreas 
below  ligature,  detached  the  peripheral  portion  to  the  extent  of  an  inch  and 
a  half,  turned  the  free  end  downward,  and  closed  the  abdominal  incision. 
Death  on  third  day.  No  haemorrhage  into  the  abdominal  cavity;  diffuse 
purulent  peritonitis;  adhesions  between  the  duodenum,  liver,  and  greater 
omentum. 


EXPERIMENTS   ON   THE   PANCREAS.  335 

Experiment  38.  Young  cat,  same  operation  as  in  previous  experiment. 
No  serious  symptoms  were  observed  after  the  operation.  About  two  weeks 
later  progressive  emaciation,  until  the  animal  died  forty-two  days  after 
operation.  At  the  post-mortem,  an  extensive  abscess  was  found  underneath 
the  skin  over  the  sacrum.  Some  evidences  of  previous  peritonitis,  but  no 
effusion  or  suppuration.  Duodenal  or  detached  portion  quite  vascular,  but  in 
a  condition  of  advanced  atrophy.  Splenic  portion  was  normal  in  size  and 
appearance,  but  cut  end  was  firmly  adherent  to  the  duodenum  below  the 
entrance  of  the  common  duct. 

Experiment  39.  Young  cat.  Operation  the  same,  followed  by  no  serious 
symptoms  and  no  rise  in  temperature.  Animal  was  killed  seventy  days  after 
the  operation.  At  the  autopsy  the  lower  border  of  the  liver  was  found  adher- 
ent to  the  cicatrix  of  the  abdominal  wound.  Duodenal  portion  was  completely 
atrophied.  At  the  point  where  the  duodenum  was  denuded  of  its  mesentery, 
the  bowel  had  become  acutely  flexed  by  cicatricial  contraction  which  approxi- 
mated the  raw  surfaces.  The  same  .cicatrix  connected  the  atrophied  and 
intact  portion  of  the  pancreas. 

Experiment  40.  Adult  cat.  Pancreas  detached  from  duodenum  to  the 
extent  of  an  inch  and  a  half,  otherwise  operation  same  as  in  preceding  cases. 
Rise  in  temperature  on  fourth  and  seventh  day,  otherwise  the  animal  was  in 
good  condition.  Killed  forty-two  days  after  the  operation.  Animal  was  well 
nourished.  Great  omentum  adherent  to  cicatrix  of  wound.  At  the  point 
where  the  gland  was  detached  from  the  duodenum,  the  bowel  doubled  upon 
itself  acutely,  the  raw  mesenteric  surfaces  being  in  direct  contact.  The  con- 
nective tissue  remnant  of  the  duodenal  portion  was  incorporated  in  this 
cicatrix  but  could  be  readily  identified.  Cut  surface  of  splenic  end  was  firmly 
adherent  to  the  duodenum  below  the  entrance  of  the  common  duct;  presented 
normal  appearance  in  size,  structure  and  shape. 

Experiment  41.  Young  cat.  Operation  the  same  as  in  preceding  case. 
Temperature  on  fifth  day,  105.5°  F.  Animal  was  killed  on  seventh  day: 
wound  not  completely  healed;  abscess  on  concave  side  of  the  duodenum;  no 
peritoneal  effusion  or  signs  of  general  peritonitis. 

Experiment  42.  Adult  dog;  weight  thirteen  pounds.  Operation  same  as 
before,  mesenteric  denudation  of  duodenum  two  inches.  From  second  to 
eighth  day  slight  rise  in  temperature.  Animal  in  excellent  condition  when 
killed  thirty-five  days  after  operation.  Small  ventral  hernia.  A  number  of 
adhesions  at  site  of  operation.  Mesenteric  circulation  at  point  of  detachment 
restored  by  a  plexus  of  new  vessels,  contained  in  a  narrow  band  of  cicatricial 
tissue.  Duodenal  portion  almost  completely  absorbed,  only  a  few  scattered 
imperfect  lobules  visible.  Splenic  end  normal  and  in  communication  with 
duodenum  through  common  duct. 

Experiment  43.  Adult  dog;  weight  fifteen  pounds.  Operation  same  as 
in  preceding  experiment.  No  disturbance  of  digestion  or  nutrition,  and  no 
rise  in  temperature.  Animal  was  in  good  condition  when  killed  thirty-live 
day-   alter   operation.     Duodenal   portion   indurated    and   contracted   into    a 


336 


EXPERIMENTAL   SURGERY. 


hard  string  which  contained  a  dilated  duct.  Liver  adherent  to  diaphragm. 
Duodenum  without  a  proper  mesentery  over  a  space  of  several  inches,  vascu- 
lar supply  furnished  by  new  vessels  passing  along  the  surface  of  the  bowel  on 
the  concave  side.  Examination  showed  that  ligature  had  been  applied  on 
splenic  side  of  duct,  and  that  the  section  had  probably  been  made  near  or 
through  the  common  duct,  as  the  splenic  portion  was  also  in  a  state  of 
advanced  atrophy  and  not  in  communication  with  the  bowel.  The  duodenal 
portion  was  in  a  state  of  extreme  atrophy,  much  shortened,  and  firmly 
adherent  to  the  bowel.  Just  below  point  of  operation,  a  small  encapsulated 
abscess  was  found  on  the  convex  side  of  the  bowel.  In  this  case  no  pancreatic 
juice  could  gain  entrance  into  the  bowel,  and  yet  digestion  and  nutrition 
appeared  to  be  unimpaired. 

Remarks. — As  in  cases  of  external  pancreatic  fistula  the  secre- 
tions often  amounted  to  more  than  four  ounces  a  day,  we  have  every 
reason  to  believe  that  the  same  quantity  was  secreted  and  discharged 
into  the  peritoneal  cavity  in  the  cases  in  which  an  internal  pancreatic 
fistula  was  established.  The  effect,  if  any,  of  the  pancreatic  juice 
upon  the  peritoneum  can  be  seen  best  by  an  examination  of  the 
following  table: 


Experiment 
No. 

Animal. 

Time  of  death. 

Cause  of  death. 

33 

Dog, 

76  days, 

Purulent  peritonitis. 

34 

M 

3      " 

Killed. 

35 

U 

Living, 

Ran  away  32d.  day. 

36 

Cat, 

83  days, 

Killed. 

37 

u 

3      " 

Purulent  peritonitis. 

38 

" 

42      " 

Abscess  in  sacral  region. 

39 

I( 

70      " 

Killed. 

40 

u 

42      " 

" 

41 

l< 

7      " 

« 

42 

Dog, 

35      " 

it 

43 

35      " 

a 

In  only  two  of  the  eleven  experiments  was  death  caused  by 
purulent  peritonitis.  In  one  a  circumscribed  abscess  was  found  in 
the  concavity  of  the  duodenum,  and  in  one  animal  a  small  abscess, 
with  thick  walls,  was  found  on  the  convex  surface  of  the  duodenum, 
which  did  not  give  rise  to  any  symptoms  during  life.  One  of  the 
cats  died  from  the  consequences  of  a  large  abscess  over  the  sacrum, 
forty-two  days  after  the  operation.  The  post-mortem  appearances 
in  the  abdomen  pointed  to  only  a  very  circumscribed  peritonitis  at 
the  seat  of  operation.     As  the  mortality  after  the  formation  of  an 


EXPERIMENTS   ON   THE   PANCREAS.  337 

internal  pancreatic  fistula  did  not  exceed  the  death-rate  of  any  other 
form  of  operation  upon  the  pancreas,  we  are  justified  in  the  assertion 
that  normal  pancreatic  juice  when  brought  in  contact  with  the 
peritoneum  does  not  produce  peritonitis. 

Another  question  which  presents  itself  is  this :  What  becomes  of 
the  pancreatic  juice  in  the  peritoneal  cavity  ?  No  mention  is  made 
in  the  autopsy  records  of  these  cases  of  the  presence  of  any  kind  of 
effusion  in  the  peritoneal  cavity,  except  in  the  two  cases  where  death 
resulted  from  purulent  peritonitis,  when  the  abdomen  contained  a 
considerable  quantity  of  a  sero-purulent  fluid  thrown  out  by  the 
inflamed  serous  membrane.  From  these  evidences  we  can  only  arrive 
at  the  legitimate  and  logical  conclusion  that  normal  pancreatic  juice 
is  promptly  and  rapidly  removed  by  absorption  when  brought  in 
contact  with  the  peritoneum.  The  uniformity  with  which  the 
detached  portion  of  the  pancreas  was  found  atrophied,  only  cor- 
roborates the  statements  previously  made  when  we  considered  the 
same  question  in  connection  with  external  pancreatic  fistula. 

Another  incidental  observation  of  considerable  importance  was 
made  concerning  the  danger  of  gangrene  of  the  duodenum  in  case 
the  mesentery  is  detached  to  any  considerable  extent.  In  all  of 
these  experiments  the  duodenum  was  denuded  of  its  mesentery,  and 
consequently  deprived  of  its  direct  vascular  supply  to  the  extent  of 
from  one  to  three  inches,  and  yet  in  no  case  was  the  duodenum 
found  gangrenous.  As  in  other  experiments  upon  the  pancreas, 
the  duodenum  showed  a  marked  immunity  against  gangrene  from 
interruption  of  its  vascular  supply.  The  last  experiment  is  of  great 
importance,  as  it  illustrates  that  digestion  may  remain  unimpaired 
even  if  no  pancreatic  juice  is  produced,  or  in  the  event  of  its  secre- 
tion not  gaining  entrance  into  the  intestine  on  account  of  complete 
and  permanent  obliteration  of  the  common  or  principal  pancreatic 
ducts.  The  ligation  experiments,  as  well  as  the  internal  pancreatic 
fistula,  also  corroborate  the  statement  made  by  some  authors,  that 
the  introduction  into  the  circulation  of  normal  pancreatic  juice  is 
innocuous,  and  that  this  abnormal  supply  is  tolerated  for  two  weeks 
or  more  without  any  appreciable  ill  consequences. 


338  EXPERIMENTAL   SURGERY. 

V.     Wounds  of  the  Pancreas. 

Of  all  abdominal  organs  the  pancreas  is  most  exempt  from 
injury,  both  from  direct  and  indirect  violence;  a  circumstance  which 
is  entirely  due  to  its  remote  location,  and  the  ample  protection  fur- 
nished by  the  vertebral  column  and  the  bony  walls  of  the  chest.  The 
anatomical  relations  of  the  pancreas  to  numerous  and  important 
organs  are  such  that  when  this  organ  is  injured,  the  same  violence 
which  has  produced  the  injury  has  also  wounded  an  adjacent  and 
perhaps  more  important  viscus.  The  frequency  with  which  such 
grave  complications  attend  wounds  of  the  pancreas,  and  the  profuse 
haemorrhage  which  usually  attends  such  injury,  are  elements  of 
danger  which  impart  to  wounds  of  the  pancreas  more  than  an 
ordinary  degree  of  gravity. 

I.    Contusion. 

Case  1.  Cooper '  reports  the  case  of  a  man,  aged  thirty-three  years,  run 
over  by  a  light  cart,  moving  with  great  speed.  No  marks  of  external  injury 
were  visible,  but  the  lower  left  ribs  were  fractured,  and  the  pancreas  was 
literally  smashed,  and  embedded  in  semi-coagulated  blood.  The  spleen  and 
left  kidney  were  also  ruptured.     He  died  a  few  days  after  the  accident. 

Case  2.  Travers2  observed  a  case  of  laceration  of  the  pancreas  at  St. 
Thomas'  Hospital.  A.n  intoxicated  woman  was  knocked  down  by  the  wheel 
of  a  stage-coach,  which,  however,  did  not  pass  over  her.  She  lived  only  a  few 
hours.  Several  ribs  were  fractured;  the  pancreas  was  found  completely  torn 
through  transversely,  the  liver  was  lacerated,  and  much  blood  was  effused. 

Case  3.  Storck  3  mentions  the  case  of  a  woman  who  was  run  over  by  a 
coach,  and  who  died  within  a  few  hours.  The  pancreas  was  found  completely 
torn  in  two,  and  embedded  in  a  large  mass  of  semifluid  blood.  Several  ribs 
were  fractured,  and  the  liver  was  also  ruptured. 

Case  4.  M.  Le  Gros  Clark  *  observed  an  instance  of  subcutaneous  lacera- 
tion of  the  pancreas,  which  occurred  in  a  lad  who  was  also  the  subject  of  other 
severe  injuries  which  speedily  proved  fatal. 

2.     Penetrating  Wound   of  Abdomen,  with   Protrusion   of 

Pancreas. 

Case  5.  Laborderie  5  reports  the  case  of  a  girl,  aged  ten  years,  who  had 
fallen,  while  running,  upon  an  open  pocket-knife,  which  inflicted  a  wound  two 

1  The  Lancet,  Dec.  31,  1839,  vol.  i.  p.  486. 

2  The  Lancet,  1827,  vol.  xii.  p.  384. 
8  Annus  Medicus,  1836,  p.  244. 

4  Lect.  on  Principles  Surgical  Diagnosis,  1870,  p.  298. 

5  Gazette  des  Hopitaux,  No.  2,  1856. 


WOUNDS   OF   THE   PANCREAS.  339 

centimeters  below  the  lower  border  of  the  rib,  and  three  fingers'  breadth  to 
the  right  of  the  median  line,  extending  outward  for  one  and  a  half  centi- 
meters, almost  horizontal,  with  a  little  inclination  from  above  downward.  The 
pancreas  was  found  strangulated  in  the  wound  so  tightly  that  not  a  drop  of 
blood  escaped.  The  author  believed  that  the  prolapse  was  caused  by  the 
screaming  of  the  patient.  The  duct  of  Wirsung  and  vessels  escaped  injury. 
The  abdomen  was  painless  on  palpation,  and  there  were  no  signs  of  internal 
haemorrhage.  The  knife  had  entered  the  abdomen  under  the  lobus  Spigelii 
of  the  liver,  and  in  its  course  reached  the  stomach,  cut  through  the  gastro- 
hepatic  omentum,  and  then  penetrated  between  the  liver  and  pylorus  to  the 
pancreas,  without  injuring  any  of  the  many  large  vessels  in  the  locality 
through  which  it  passed. 

An  attempt  to  replace  the  gland  was  only  partially  successful.  The  mass 
was  transfixed  and  tied  at  its  base  with  a  double  ligature,  and  the  portion 
outside  of  the  ligature  removed  with  the  knife.  After  this  procedure  nausea 
and  vomiting  set  in,  which,  however,  soon  subsided.  The  wound  was  treated 
by  the  use  of  cold  water  applications.  On  the  third  day  the  patient  com- 
plained of  being  chilly,  and  the  abdomen  became  somewhat  tympanitic  and 
tender  on  pressure.  These  symptoms  soon  subsided,  and  the  ligatures 
sloughed  through,  leaving  a  granulating  surface,  which  healed  in  fourteen  days. 
Recovery  was  complete  in  three  weeks. 

Remarks. — Hyrtl  and  Klebs  are  incredulous  as  to  the  prolapse 
of  the  pancreas  in  this  case;  they  believe  that  the  mass  ligated  and 
removed  was  not  the  gland,  but  a  portion  of  the  omentum.  Nuss- 
baum,1  however,  in  speaking  of  visceral  injuries  of  the  pancreas, 
states  distinctly  that  in  penetrating  wounds  of  the  abdomen  in  the 
region  of  the  pancreas,  this  organ  manifests  a  tendency  to  prolapse, 
and  that  this  circumstance  facilitates  the  treatment,  as  it  protects  the 
peritoneal  cavity  against  infection,  by  plugging  the  wound,  and  at 
the  same  time  affords  better  access  to  the  bleeding  vessels. 

Case  6.  Dargau  -  saw  a  case  in  which  the  pancreas  protruded  through 
a  wound  five  inches  in  length,  between  the  last  two  false  ribs,  on  the  left  side. 
The  patient  was  a  negro,  who  had  been  injured  fourteen  hours  before  he 
came  under  treatment.  The  pancreas  was  replaced,  the  wound  closed,  and 
the  patient  made  a  good  recovery. 

Case  7.  Caldwell3  reports  the  following  remarkable  case:  In  1816,  a 
negro  was  stabbed  in  the  left  side,  and  "an  oblong  body,  between  three  and 
four  inches  in  length,  was  observed  to  have  protruded."  Drs.  Roberts,  Heard, 
and  Caldwell  supposed  the  protruded  part  might  be  mesentery,  omentum,  or 
lung  substance;  but,  on  a  more  minute  examination,  that  opinion  was  changed 

1  Die  Verletzungen  des  Unterleibes,  1880. 

2  Medical  and  Surgical  Reporter,  Aug.  22,  1874. 

1  Transylvania  Journal  of  Medicine,  1828,  vol.  i.  p.  116. 


340  EXPERIMENTAL  SURGERY. 

to  the  belief  that  it  was  the  small  extremity  of  the  pancreas.  The  protruding 
part  was  in  a  gangrenous  condition,  and  was  removed  with  the  knife.  The 
patient  soon  recovered.  The  gentlemen  who  treated  the  case,  "  thinking  it 
almost  impossible  that  the  pancreas  could  escape  through  a  part  of  the  dia- 
phragm and  between  the  ribs,"  made  a  critical  examination  of  the  part  removed, 
which  resulted  in  their  thorough  conviction  that  the  tissue  removed  was  a  por 
tion  of  the  pancreas. 

Case  8.  Kleberg,  who,  together  with  Dr.  Wagner,  Jr.,  examined  the  speci- 
men of  pancreas  microscopically,  reports  the  following  case: 1  A.  S.,  aged  sixty, 
a  discharged  soldier,  of  powerful  frame,  and  a  drinker,  was  surprised  while  com- 
mitting a  burglary,  and  cut  in  the  abdomen  with  a  knife  from  below  upward, 
while  stooping  over.  He  was  carried  into  the  surgical  wards  of  the  hospital  at 
6  a.m.,  having  a  cut  in  the  abdomen  running  horizontally  about  twelve  inches 
in  length,  between  the  navel  and  lower  border  of  the  ribs  on  the  right  side. 
Protruding  from  the  wound  was  a  brown-red  body  about  three  inches  long  by 
two  inches  in  width,  of  a  doughy  consistence  and  covered  by  a  smooth  mem- 
brane. Immediately  after  entering  the  hospital  he  had  a  normal  passage 
through  the  bowels;  pulse  72;  no  pain.  The  stomach,  intestines,  and  liver 
could  be  excluded  on  examining  the  appearance  and  physical  properties  of 
the  projecting  body.  There  was  no  fat,  as  would  have  been  the  case  had  it 
been  the  omentum  of  such  a  corpulent  person.  The  prolapsed  body  was  com- 
pact and  homogeneous,  could  not  be  separated  into  layers,  and  presented  no 
dilated  vessels.     It  was,  therefore,  taken  to  be  the  head  of  the  pancreas. 

As  reposition  of  the  protruding  part  did  not  appear  advisable,  on  account 
of  a  possible  constriction,  and  as  the  consequences  could  not  be  foreseen,  the 
part  was  fixed  in  the  wound  with  two  Karlsbad  needles,  which  were  passed 
through  the  sides  of  the  wound  and  the  protruding  part;  a  silk  ligature  was 
then  passed  around  the  pedicle  of  the  protruding  part  and  the  end  cut  off 
with  one  stroke  of  the  knife;  the  profuse  oozing  of  blood  was  stopped  by 
tightening  the  ligature.  The  stump  was  touched  with  liq.  ferri  sesquichlor., 
and  cold  applications  made  over  the  whole  abdomen.  There  was  no  fever, 
peritonitis,  or  disturbance  of  digestion  in  the  course  of  the  recovery.  The 
needles  and  sutures  were  removed  on  the  fourth  day;  the  stump  had  become 
adherent  to  the  edges  of  the  wound.  The  stump  and  ligature  came  away  on 
the  tenth  day.  The  patient  left  the  hospital  twenty  days  after  admission, 
with  a  three-cornered  depressed  scar.  As  he  was  perfectly  well  nourished 
during  the  entire  time,  it  is  probable  that  the  caudal  extremity  of  the  gland 
was  removed  and  that  the  portion  of  the  gland  remaining,  with  the  excretory 
duct,  performed  the  functions  of  the  gland  adequately. 

Case  9.  Assistant  Surgeon  J.  G.  Thompson,  77th  New  York,2  reports  the 
case  of  "  a  soldier,  name  unknown,  who  was  wounded  at  Cedar  Creek,  October 
19,  1864.     The  ball  entered  the  right  side,  below  the  ribs,  and  emerged  on  the 

1  Langenbeck's  Archiv  fur  Chirurgie,  vol.  ix.  p.  523. 

2  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  part  ii.  vol.  ii. 
Surgical  History,  p.  158. 


WOUNDS   OF  THE  PANCREAS.  341 

left  side.  He  was  removed  to  the  Taylor  Hospital,  at  Winchester.  While 
straining  at  stool,  two  days  subsequently,  a  hernia  of  the  pancreas  occurred  of 
the  size  of  a  hen's  egg.  A  silver  wire  was  passed  about  the  pedicle  by  which  it 
was  attached,  and  twisted  tighter  each  day  for  about  a  week,  until  it  became  very 
small,  and  was  snipped  off  with  scissors.  No  especial  symptoms  supervened, 
and  by  the  last  of  November  the  patient  was  in  a  fair  way  toward  recovery, 
and  was  moving  about  the  hospital.     In  December  he  was  still  doing  well." 

Case  10.1  Private  William  Freshwater,  Co.  F.,  66th  Ohio,  received  wounds 
of  the  abdomen,  left  forearm,  and  neck,  at  Port  Republic,  June  9,  1862.  He 
way  conveyed  to  Port  Royal,  arriving  on  the  13th,  and  on  the  14th  was  sent 
by  rail  to  Washington,  and  admitted,  on  the  15th,  to  Judiciary  Square  Hospital. 
He  was  placed  in  a  ward  under  the  charge  of  Acting  Surgeon  D.  W.  Cheever, 
who  states  that  "  a  ball  had  entered  one  and  a  half  inches  ontside  the  left 
nipple,  on  a  level  with  the  seventh  rib,  and  could  be  felt  under  the  skin  near 
the  spinous  process  of  the  last  dorsal  vertebra.  Some  viscus,  thought  to  be 
the  lower  tip  of  the  lung,  protruded  at  the  wound.  He  died  in  two  days  (June 
17th)  with  symptoms  of  peritonitis.  Post-mortem:  The  ball  had  pierced  the 
diaphragm  without  touching  the  lower  lobe  of  the  lung;  there  was  no  perfora- 
tion of  the  intestines,  but  they  were  glued  together  by  peritoneal  inflamma- 
tion.    The  pancreas  protruded  at  the  wound." 

3.     Gunshot  Wounds. 

The  only  cases  of  gunshot  wounds  of  the  pancreas  that  I  have 
been  able  to  find  are  reported  by  Otis." 

Case  11.  Private  J.  Koprieau,  Co.  B.,  51st  New  York,  aged  thirty-two 
years,  was  severely  wounded  at  the  battle  of  the  Wilderness,  May  5,  1864,  and 
was  at  once  taken  to  the  field  hospital  of  the  2d  division,  Ninth  Corps.  As  the 
patient  could  not  talk  English,  the  history  of  the  case  is  quite  imperfect. 
Assistant  Surgeon  J.  C.  McKer  furnished  the  following  description,  which  I 
have  abbreviated  without  omitting  essential  facts: 

The  patient  came  under  his  care  May  25,  1864,  when  it  was  ascertained 
that  he  was  suffering  from  a  gunshot  wound  of  the  back,  the  ball  entering 
about  six  inches  to  the  left  of  the  sjiiiial  column,  having  pushed  below  the 
eighth  or  ninth  rib.  It  was  evident  that  the  ball  had  entered  the  abdominal 
cavity,  but  its  course  could  not  be  ascertained.  Patient's  general  health  was 
apparently  good,  and  he  seemed  to  suffer  but  little  pain  from  the  injury. 
Appetite  good,  bowels  regular,  urine  slightly  suppressed  and  somewhat  highly 
colored.  Pulse  normally  full,  but  slightly  irritable.  The  patient  was  ordered 
quinine,  whiskey,  nourishing  diet,  and  two  doses  of  acetate  of  potassa.  No 
noticeable  change  appeared  for  about  one  week,  when  a  severe  ha?morrhage 
occurred,  apparently  venous, from  the  external  wound,  which  was  soon  arrested 
by  tlie  use  of  compresses  and  styptics.  About  six  hours  afterward  a  quantity 
of  urine  was  voided,  which  was  thickly  mixed  with  blood.    These  htemorrhages 

1  Ibid.,  page  168. 

2  Ibid.,  page  159. 


342 


EXPERIMENTAL  SURGERY. 


continued  to  recur  two,  three,  and  four  times  daily  till  death,  the  urinal 
discharge  being  very  frequent,  and  always  bloody.  Death  resulted  June  5, 
1864. 

Post-mortem  examination  revealed  the  following:  A  minie-ball  entered 
at  the  middle  portion  of  the  eighth  rib,  fracturing  the  same,  passed  through 
the  center  of  the  spleen  towards  the  pancreas,  penetrating  this  also  in  a  nearly 
transverse  direction,  and  (probably  a  few  days  before  death)  sinking  toward 
the  splenic  artery,  tearing  it,  and  lodged  at  its  origin  from  the  cceliac  axis; 
the  lung  was  found  emphysematous.  The  ball  was  found  embedded  in  the 
pancreas  in  a  pouch  between  the  sloughing  artery  and  vein.  The  specimen  is 
preserved  as  a  wet  preparation  in  the  Army  Medical  Museum,  and  is  marked 
No.  2430.     (Fig.  21.) 


Fig.  21.     A  wet  preparation  of  portions  of  spleen,  pancreas,  kidney, 

and  cceliac  axis,  showing  musket-ball  embedded  in  the 

pancreas. 

Specimen,  Army  Medical  Museum,  No.  2430. 


Case  12.  Corporal  A.  B.  Jones,  Co.  D.,  5th  Vermont,  aged  twenty-seven 
years,  was  wounded  at  the  battle  of  the  Wilderness,  May  10,  1864,  and  laid  on  the 
battlefield  one  day  and  night;  was  then  removed  to  the  field  hospital, from  there 
carried  by  boat  to  Washington,  and  jolted  over  a  rough  road  of  two  miles  to  the 
Lincoln  Hospital,  which  he  reached  about  two  o'clock  in  the  morning  of 
the  25th.  Was  seen  a  few  hours  afterward  by  Acting  Assistant  Surgeon  T.  L. 
Lea'vitt,  who  found  him  suffering  great  agony.  On  examination  it  was  found 
that  the  ball  had  entered  one  line  to  the  left  and  below  the  ensiform  cartilage, 
passing  through  the  abdominal  cavity,  and  making  its  appearance  under  the 


WOUNDS   OF  THE  PANCREAS.  343 

skin  just  above  the  crest  of  the  ilium  posteriorly,  where  it  was  excised  at  the 
field  hospital.  Pulse  quick  and  exceedingly  feeble,  abdomen  distended  and 
tympanitic.  Opium  was  administered  and  the  patient  took  liquid  food  freely. 
About  noon  of  the  same  day  the  symptoms  improved,  wound  suppurating 
nicely.  About  four  o'clock  was  conversing  with  nurse,  apparently  in  good 
spirits,  without  very  great  pain;  in  about  five  minutes  afterward  was  in  articulo 
mortis. 

The  autopsy  showed  the  ball  to  have  perforated  the  inferior  curvature  of 
the  stomach,  and,  strange  as  it  may  seem,  although  an  orifice  was  made 
directly  through  the  walls  of  the  stomach  large  enough  to  readily  admit  two 
fingers,  no  inflammation  or  even  congestion  could  be  detected,  except  in  the 
immediate  locality  of  the  wound,  which  was  beginning  to  suppurate.  Evi- 
dently the  stomach  was  also  uninjured  in  its  functional  capacity,  as  was 
witnessed  by  the  reception  and  digestion  of  food  during  life.  Some  branches 
of  the  gastric  artery  were  severed,  and  about  an  ounce  and  a  half  of  dark 
uncoagulated  blood  was  found.  The  pancreas  was  perforated  at  about  its 
middle,  but,  except  in  the  immediate  track  of  the  ball,  gave  evidence  of  no 
departure  from  its  healthy  standard;  the  intestine  and  colon  were  pushed 
aside  during  the  passage  of  the  ball  and  were  uninjured;  the  omentum  was 
found  in  a  state  of  partial  decomposition  and  closely  adherent  to  the  small 
intestine.  Liver  and  spleen  healthy.  General  peritonitis  had  prevailed  and 
was  undoubtedly  the  cause  of  death.  In  this  case  life  was  sustained  for  a 
period  of  fifteen  days,  notwithstanding  the  serious  injury  of  a  vital  organ  and 
the  exposure  to  most  unfavorable  circumstances  and  depressing  influences. 

Case  13.  Private  William  P.  B.,  Co.  A.,  44th  Georgia,  was  wounded  near 
Fort  Stevens,  in  General  Early's  demonstration  on  Washington,  July  12,  1864, 
by  a  cylindrico-conical  musket-ball,  which  entered  below  the  spine  of  the  left 
scapula,  an  inch  from  the  shoulder-joint,  and  penetrated  the  chest.  He 
remained  a  prisoner  on  the  field,  and  was  conveyed  to  Lincoln  Hospital,  a  few 
miles  distant,  being  admitted  on  July  14th.  He  was  examined  by  Dr.  Leavitt, 
who  found  that  emphysema  extended  over  the  entire  left  chest,  that  respira- 
tion was  painful,  but  not  otherwise  difficult,  and  that  there  was  paralysis  of 
motion  of  the  left  arm.  There  was  little  change  in  the  progress  of  the  case 
until  the  18th,  when  the  pain  in  the  side  became  severe,  and  was  somewhat 
relieved  by  sinapisms.  Following  day,  dullness  over  posterior  left  chest,  also 
extreme  dullness  in  the  precordial  region  and  the  heart  was  forced  over  to  the 
right  side.  There  was  dullness  too  at  the  base  of  the  right  lung,  with  indistinct 
respiratory  murmur.  On  the  20th,  jaundice  was  very  pronounced.  On  the 
21st,  profuse  hemorrhage  from  the  nose  and  mouth  occurred,  bleeding  com- 
ing apparently  from  the  lung.  Pulse  at  this  time  very  weak  and  thready; 
jaundice  extreme.  On  the  22nd,  there  was  much  pain  in  the  left  side,  dyspnoea, 
consciousness  perfect,  pulse  failing;  death  at  noon,  July  24,  18(54,  twelve  days 
after  the  injury. 

At  the  autopsy  the  wound  was  traced  from  the  entrance  in  the  scapula 
through  the  fractured  fifth  rib,  the  track  passing  downward,  inward,  and 
backward,  through  the  Lower  lobe  of  the  left  lung,  the  diaphragm  and  the  left 


344  EXPERIMENTAL   SURGERY. 

lobe  of  the  liver  to  the  head  of  the  pancreas,  where  the  ball  was  found  lodged 
in  the  head  of  the  viscus,  at  the  angle  formed  by  the  cceliac  axis  with  the 
aorta.  The  lower  lobe  of  the  right  lung  was  hepatized;  the  left  lung  carnified, 
collapsed  and  compressed  by  a  large  accumulation  of  black  fluid  blood.  The 
pancreas  was  rather  large — seven  inches  long;  weight,  with  ball,  five  ounces. 
There  was  nothing  abnormal  in  its  appearance,  except  the  presence  of  the 
foreign  body.  On  examining  the  pancreas  microscopically  no  deviation  from 
the  normal  structure  was  found  in  sections  made  from  the  tissue  taken  from 
the  left  end  or  tail  of  the  viscus  and  from  the  middle  part.  In  close  contiguity 
to  the  ball  was  a  fine  network  of  fibrillated  tissue.  As  hardened  in  alcohol  the 
specimen  offers  no  indication  of  vascular  engorgement  having  existed.  The 
specimen  is  preserved  in  the  Army  Medical  Museum,  and  is  marked  No.  2884. 
(Fig.  22.) 


Fig.  22.     Pancreas  with  a  conoidal  musket-ball  embedded  in  its  head. 
Specimen,  Army  Medical  Museum,  No.  2884. 

Eemaeks. — Not  in  a  single  instance  of  the  thirteen  cases  of 
injury  of  the  pancreas,  as  reported  above,  did  symptoms  during  life 
first  point  to  this  organ  as  the  seat  of  lesion.  In  all  cases  where  the 
result  was  fatal,  death  was  not  attributable  to  the  visceral  lesion  of 
the  pancreas,  but  was  always  referable  to  injury  of  some  adjacent 
organ.  With  the  exception  of  cases  of  prolapse  of  this  organ 
through  a  penetrating  wound  of  the  abdomen,  the  diagnosis  and 
treatment  of  injuries  of  the  pancreas  will  come  under  the  observa- 
tion of  surgeons  only  in  an  incidental  manner  in  the  treatment  of 
more  tangible  and  graver  lesions  within  the  abdominal  cavity. 
Contusion  and  laceration  of  the  pancreas  as  independent  conditions 
are  not  necessarily  fatal  injuries,  and  spontaneous  recovery  may 
take  place,  followed  by  absorption  of  the  crushed  portion  of  the 
organ,  and  atrophy  of  that  portion  of  the  glaud  which  has  become 
physiologically  detached  from  the  intestinal  tract  by  the  injury  or 


WOUNDS   OF  THE  PANCREAS.  345 

Its  direct  consequences.  Crushing  of  the  pancreas  is  usually  not 
attended  by  hemorrhage,  and  in  laceration  of  the  organ  the  danger 
from  this  source  is  much  less  than  in  cases  of  incised  wounds. 

As  modern  surgery  dictates  not  only  the  justifiability  but  the 
absolute  necessity  of  treating  penetrating  wounds  of  the  abdomen, 
where  visceral  injury  is  suspected,  by  abdominal  section,  the 
surgery  of  the  future  will  undoubtedly  deal  with  contusions  and 
lacerations  of  the  pancreas  in  connection  with  visceral  injury  of 
some  of  its  adjacent  organs.  If,  in  exploring  for  injuries  in  this 
region,  the  pancreas  should  be  found  extensively  crushed,  it  would 
be  good  surgery  to  remove  the  crushed  portion,  after  preliminary 
ligation  of  -the  organ  on  each  side  of  the  comminuted  portion. 

Ligation  of  the  pancreas  can  be  safely  done  with  a  single 
catgut  or  silk  ligature,  as  the  friable  texture  of  the  organ  will 
permit  of  burying  the  ligature  deeply,  a  circumstance  which  will 
guard  against  slipping  of  the  ligature.  In  not  a  single  instance 
where  this  method  of  ligation  was  resorted  to  in  the  experiments  on 
animals,  was  secondary  haemorrhage  froin  inefficiency  of  the  ligature 
observed.  If  the  pancreas  is  lacerated,  each  end  of  the  organ  should 
be  ligated  for  the  purpose  of  arresting  or  preventing  haemorrhage, 
as  well  as  to  guard  against  extravasation  of  pancreatic  juice  into  the 
abdominal  cavity. 

The  results  obtained  by  experiments  on  animals,  as  detailed 
above,  have  demonstrated  in  a  satisfactory  manner  that  normal 
pancreatic  juice  when  brought  in  contact  with  the  peritoneum  does 
not  produce  inflammation,  but  is  promptly  removed  by  absorption. 
In  the  experimental  work  we  always  had  the  advantage  of  dealing 
with  a  normal  serous  surface,  the  absorption  capacity  of  which  had 
not  been  impaired  by  antecedent  pathological  conditions,  as  would  in 
all  probability  be  the  case  in  the  operative  treatment  of  injuries  of 
the  pancreas.  At  the  same  time  there  can  be  no  doubt  that  the 
presence  of  crushed  pancreatic  tissue  and  pancreatic  juice  in  the 
peritoneal  cavity,  after  abdominal  section,  would  greatly  enhance 
the  danger  of  traumatic  infection.  For  this  reason,  if  for  no  other, 
the  former  should  be  removed  and  the  escape  of  the  latter  prevented 
by  ligation  of  the  pancreas  on  the  side,  or  each  side,  of  the  crushed 
or  lacerated  portion. 

The  cases  of  protrusion  of  the  pancreas  seem  to  establish  the 
fact  that  a  portion  of  this  viscus  may  be  separated  by  violence  from 


346  EXPERIMENTAL   SURGERY. 

the  splenic  artery  and  other  important  attachments,  and  may 
prolapse  through  an  external  wound,  and  under  such  circumstances 
be  removed  without  hazardous  consequences.  In  most  cases  the 
prolapse  followed  some  time  after  the  injury,  from  a  sudden  increase 
of  intra-abdominal  pressure,  as  coughing  or  straining  at  stool. 

Klebs  and  Hyrtl's  objection  to  the  possibility  of  a  hernia  of 
the  pancreas,  can  find  a  plausible  support  only  by  assuming  that 
the  relations  of  the  pancreas  have  not  been  disturbed.  If,  by  the 
violence  which  produced  the  penetrating  wound,  the  attachments  of 
the  organ  are  severed,  or  in  case  the  attachments  have  been  abnor- 
mally loose,  or  the  duodenum  is  supplied  with  a  long  mesentery, 
there  is  no  tenable  reason  why  the  pancreas  should  not  occasionally 
be  found  protruding  through  the  external  wound.  Cases  are  on 
record  where  the  pancreas  constituted  one  of  the  contents  of  a 
diaphragmatic  hernia,  and  an  instance  is  reported  where  it  formed  a 
part  of  the  intussusceptum  in  a  case  of  invagination  of  the  bowel 
(Bandl). 

The  treatment  of  prolapse  of  the  pancreas  will  depend  upon 
the  pathological  condition  of  the  viscus  at  the  time  the  patient 
comes  under  the  care  of  the  surgeon.  If  the  prolapse  is  recent  and 
the  organ  presents  no  indication  of  inflammatory  or  other  changes, 
it  should  be  thoroughly  disinfected  and  replaced.  It  is  of  the 
greatest  importance  not  to  resort  to  violence  in  effecting  reduction, 
as  irreparable  damage  may  be  inflicted  by  resorting  to  more  than 
the  gentlest  force.  When  reduction  is  not  readily  accomplished,  the 
wound  should  be  enlarged.  If  the  pancreas  is  in  a  condition  of 
inflammation  or  gangrene,  the  parts  should  be  thoroughly  disinfected 
and  the  organ  pulled  further  into  the  wound  until  healthy  tissue  is 
reached,  when  a  ligature  is  applied  and  the  diseased  portion 
removed  with  the  knife  or  scissors.  After  another  thorough  disin- 
fection the  stump  is  dropped  into  the  abdominal  cavity  and  the 
external  wound  closed.  Thorough  primary  removal  of  infected 
tissue  is  the  only  safety  against  subsequent  extension  of  the  infection 
to  the  peritoneal  cavity,  and  the  only  guarantee  for  primary  union  of 
the  abdominal  wound. 

In  gunshot  wounds  of  the  pancreas  we  have  no  guiding  symp- 
toms upon  which  to  base  even  a  probable  diagnosis.  The  point  of 
entrance  and  exit  of  the  ball,  and  its  probable  course,  are  the  only 
facts  which  may  point  to  the  pancreas  as  one  of  the  injured  organs. 


WOUNDS   OF   THE  PANCREAS.  347 

In  four  of  the  five  eases,  the  projectile  penetrated  posteriorly  in  the 
space  between  the  angle  of  the  left  scapula  and  the  angles  of  the 
ribs,  and  passed  through  the  diaphragm  and  the  solar  plexiis;  in  one 
the  ball  entered  anteriorly  near  the  tip  of  the  xiphoid  cartilage, 
and  was  believed  to  have  passed  through  the  stomach. 

It  is  a  notable  and  somewhat  significant  fact,  that  in  all  cases 
where  life  was  prolonged  for  more  than  twelve  days,  the  pancreas 
appeared  to  have  undergone  but  little  or  no  pathological  change  in 
the  vicinity  of  the  visceral  wound.  Although  in  all  cases  the  track 
of  the  ball  did  not  remain  aseptic,  the  inflammatory  changes  did  not 
materially  affect  the  parenchyma  of  the  gland. 

In  case  13  the  formation  of  a  capsule  around  the  bullet  had 
already  been  initiated,  and  if  the  patient  had  lived,  there  is  every 
reason  to  believe  that  the  foreign  body  would  have  become  encysted 
in  the  parenchyma  of  the  pancreas. 

Gunshot  injuries  of  the  pancreas,  when  they  come  under  the 
observation  of  the  surgeon  as  an  independent  lesion,  or  as  a  compli- 
cation of  other  visceral  injuries  in  cases  of  penetrating  wounds  of  the 
abdomen  treated  by  laparotomy,  should  be  treated  in  the  same  way 
as  a  contusion  or  laceration  of  the  gland.  The  results  obtained  by 
the  experiments  have  shown  that  if  only  a  comparatively  small 
portion  of  the  pancreas  remains  in  physiological  connection  with  the 
duodenum,  this  portion  of  the  gland  retains  its  normal  structure  and 
its  physiological  function;  which,  in  all  of  the  experimental  cases, 
was  found  adequate  to  supply  the  requisite  quantity  of  pancreatic 
juice  necessary  for  the  maintenance  of  normal  digestion. 

While  the  surgeon  may  unhesitatingly  remove  the  tail  and  a 
portion  of  the  body  of  the  pancreas  without  fear  of  any  immediate 
or  remote  ill  effects,  great  care  must  be  exercised  in  operating  in  the 
vicinity  of  the  head  of  the  pancreas  to  preserve  the  integrity  of 
the  common  duct,  and  as  much  of  this  portion  of  the  organ  as  may 
appear  compatible  with  the  condition  which  necessitated  the 
operation. 

The  results  of  the  experiments  made  with  a  view  to  ascertain 
how  much  of  the  mesentery  of  the  duodenum  can  be  detached 
without  causing  gangrene  of  the  bowel  have  been  stich  as  to  encour- 
;rjf  a  conservative  plan  of  treatment  when  operating  in  close  prox- 
imity to  the  intestine.  The  observations  mad**  in  this  direction  have 
shown  that    it   is  comparatively  safe  to  detach    a,   portion   of    the 


348  EXPERIMENTAL   SURGERY. 

mesentery  even  to  the  extent  of  one  to  three  inches,  a  procedure 
incomparably  easier  and  much  safer  than  enterectomy  combined 
with  partial  excision  of  the  head  of  the  pancreas.  I  wish  again  to 
emphasize  the  fact  that  complete  extirpation  of  the  head  of  the  pan- 
creas with  the  common  duct  is  never  justifiable,  and  that  operations 
upon  this  portion  of  the  gland  for  injury  or  disease  must  be  limited 
to  partial  excision  of  the  head,  with  preservation  of  the  common 
duct. 

VI.    Acute  Pancreatitis. 

Acute  idiopathic  pancreatitis  is  an  exceedingly  rare  affection; 
only  a  few  well -authenticated  cases  of  the  disease  have  been 
reported.  A  brief  consideration  of  this  affection  is  necessary  in 
connection  with  our  subject,  for  the  purpose  of  calling  attention  to  a 
few  of  the  most  constant  and  prominent  symptoms  which  characterize 
the  disease,  inasmuch  as  all  suppurative  lesions  of  this  organ,  which 
are  of  special  interest  to  the  surgeon,  are  preceded  by  inflammation. 
The  disease  originates  either  primarily  in  the  inter-acinous  connec- 
tive tissue  of  the  organ  as  a  pancreatitis,  or  it  occurs  as  a  secondary 
disease  from  extension  of  a  peripancreatitis  to  the  substance  of  the 
gland.  Haller  and  Klob  have  given  an  accurate  clinical  description 
of  a  case  observed  at  the  Allgemeines  Krankenhaus  in  Vienna,  with 
a  careful  account  of  the  post-mortem  appearances.1 

Case  1.  A  gilder,  sixty-three  years  of  age,  had  been  suffering  from  indi- 
gestion, which  was  referred  to  a  defective  stomach  digestion.  Flatulency  and 
vomiting  were  prominent  symptoms.  The  patient  was  anaemic,  and  presented 
a  cachectic  appearance;  tongue  slightly  coated,  anorexia,  epigastrium  tym- 
panitic and  tender  to  pressure.  Vomiting  of  a  thin,  yellow,  bitter  fluid. 
Slight  elevation  of  temperature;  pulse  90;  lower  extremities  cedematous.  The 
same  evening  vomiting,  collapse,  and  great  pain  in  epigastrium,  extending 
over  the  abdom,en.  During  the  night  obstinate  vomiting,  traces  of  blood  in 
the  ejected  matter;  urine  dark  colored,  contained  no  albumen.  Next  day 
vomiting  ceased,  but  collapse  increased,  followed  by  death  toward  evening. 

The  autopsy  revealed  serous  infiltration  of  gray  matter  of  brain  and 
lungs.  The  stomach  was  collapsed,  its  mucous  membrane  bulging.  The  pos- 
terior wall  of  the  stomach  was  perforated  in  three  places,  the  openings  being 
as  large  as  a  pea,  and  funnel  shaped,  with  the  larger  extremity  directed 
toward  the  peritoneal  surface.  The  edges  of  these  perforations  were  quite 
friable,  discolored,  and  continuous  with  a  fetid  abscess  cavity,  which  extended 
from  the  posterior  surface  of  the  stomach  to  the  spinal  column,  and  from  the 

1  Schmidt's  Jahrbucher,  18G0,  vol.  i.  p.  306. 


ACUTE   PANCREATITIS.  349 

spleen  to  the  pylorus,  in  which  the  pancreas  was  found  as  a  grayish,  discolored, 
flabby,  thin,  and  exceedingly  fragile  mass  infiltrated  with  pus.  In  front  of 
the  anterior  wall  a  fringed  portion  of  the  bursa  omentalis  was  found,  and  on 
the  upper  border  the  arteria  and  vena  lienales  were  seen;  the  latter  was  filled 
with  a  thrombus.  Examined  under  the  microscope  the  parenchyma  of  the 
gland  showed  that  the  cells  were  degenerated,  being  distended  and  turbid; 
acini  separated,  at  some  places  collapsed,  and  the  spaces  between  them 
contained  granules  and  large  globules  of  fat. 

Remarks. — The  course  of  the  disease  was  quite  acute,  termi- 
nating in  diffuse  suppuration  and  death,  after  an  illness  lasting  only 
sixteen  days.  The  absence  of  disease  in  any  of  the  adjacent  organs, 
and  the  advanced  pathological  changes  in  the  gland,  pointed  to  the 
pancreas  as  the  primary  starting-point  of  the  inflammation. 

Case  2.  Mayo  1  also  gives  an  interesting  description  of  a  fatal  case  of 
subacute  pancreatitis,  with  the  post-mortem  appearances.  The  patient  was 
a  lady,  twenty-one  years  of  age;  when  five  months  advanced  in  pregnancy  she 
lost  her  usual  healthy  appearance,  and  gradually  became  very  anaemic.  She 
complained  of  great  thirst,  and  also  suffered  much  from  pain  in  the  epigastric 
region,  which  was  sometimes  so  severe  as  to  oblige  her  to  retire  to  her  apart- 
ment. After  her  delivery  the  thirst  remained,  and  the  weakness  and  paleness 
increased.  Her  state  and  symptoms  were  like  those  of  persons  who  have  lost 
large  quantities  of  blood.  About  five  days  before  death  the  stomach  became 
irritable,  and  nothing  but  rennet-whey  in  small  quantities  was  retained.  She 
died  five  weeks  after  delivery.  Upon  inspecting  the  body,  the  viscera  gener- 
ally were  found  pale  and  bloodless.  Besides  serous  effusion  on  the  membranes 
of  the  brain  and  the  abdominal  organs,  no  pathological  changes  were  observed, 
except  that  the  pancreas  was  throughout  of  a  deep  and  dull  red  color,  which 
contrasted  very  remarkably  with  the  bloodless  condition  of  other  parts.  It 
was  firm  to  the  touch  externally,  and  when  an  incision  was  made  into  it,  the 
divided  lobules  felt  particularly  firm  and  crisp. 

Case  3.  Haidlen  -  reports  the  following  case  from  Fehling's  private  prac- 
tice: A  woman,  aged  thirty-three  years,  became  pregnant,  and  during  the 
period  of  gestation  had  considerable  gastric  disturbance  and  headache.  She 
remained  well  three  weeks  after  delivery,  when  there  was  some  haemorrhage. 
A  little  later  she  had  two  attacks  of  pain  in  the  region  of  the  stomach,  and 
five  and  a  half  weeks  after  delivery  she  had  a  very  severe  attack  of  pain  in  the 
pyloric  region,  accompanied  by  vomiting.  There  was  no  elevation  of  temper- 
ature; the  pulse  was  100  to  104,  and  regular.  The  epigastric  region  was 
sensitive  to  pressure,  but  there  were  no  symptoms  of  peritonitis;  the  skin  was 
pale  and  not  jaundiced.  The  patient  seemed  somewhat  collapsed.  In  the 
afternoon  of  that  day  she  seemed  worse,  the  skin  was  paler,  the  pulse  more 
rapid,  and  the  vomiting  had  ceased.     Physical  examination  showed  marked 

1  Outlines  of  Human  Pathology,  London,  1836,  p.  409. 
2Centralblatt  far  Gyniikologie,  Sept.  29,  1884. 


350  EXPERIMENTAL   SURGERY. 

swelling  of  the  abdomen,  and  great  tenderness  over  pyloric  region.  No  pelvic 
disturbances.  On  the  following  day  the  patient  was  better,  but  the  symptoms 
returned,  and  she  died,  in  collapse,  in  ninety-six  hours. 

The  autopsy  showed  that  there  was  no  peritonitis,  though  a  small  amount 
of  a  dirty,  bloody-looking  fluid  was  found  in  the  lower  part  of  the  peritoneal 
cavity.  The  organs,  with  the  exception  of  the  pancreas,  were  normal.  The 
pancreas  had  undergone  considerable  changes:  it  was  larger,  thicker,  and 
broader  than  normal,  and  its  normal  color  was  retained  in  only  a  few  places; 
it  had  changed  almost  entirely  to  a  brownish-red,  blood-suffused  mass,  con- 
taining a  small  clot  of  blood  on  the  anterior  surface,  in  contact  with  the 
mesentery,  but  there  was  no  perforation  anywhere.  The  adjacent  portion  of 
the  mesentery  was  suffused  with  blood.  Ziegler,  who  made  the  microscopic 
examination,  pronounced  the  case  one  of  acute  pancreatitis,  and  stated  that 
the  duct  of  Wirsung  was  somewhat  dilated,  and  that  he  also  found  small-celled 
infiltration  of  the  pancreatic  tissue. 

Remarks. — The  immunity  of  the  pancreas  from  disease  is  attrib- 
uted by  Gross  to  the  singular  structure  of  this  organ,  to  its  concealed 
situation,  and  to  the  absence  of  everything  like  a  proper  envelope.1 

The  first  two  cases  may  serve  as  types  of  the  two  distinct  forms 
of  inflammation  of  the  connective  tissue  of  the  pancreas,  the  suppu- 
rative and  interstitial.  Another,  the  parenchymatous  form,  is  occa- 
sionally met  with  in  the  puerperal  state,  in  cases  of  typhoid  fever, 
pyaemia,  yellow  fever,  and  other  acute  infectious  diseases,  the  post- 
mortem appearances  of  which  are  illustrated  by  case  3.  In  this 
form  the  pancreas  is  red,  swollen  and  oedematous.  In  this  variety 
the  most  prominent  microscopical  lesion  consists  in  swelling  and 
undue  granulation  of  the  glandular  epithelium,  and  hyperemia.2 

In  the  first  case  the  symptoms  were  acute,  and  the  disease  termi- 
nated in  death  in  the  short  space  of  sixteen  days.  The  suppurative 
inflammation  beginning  in  the  interstitial  tissue,  involved  the  entire 
gland,  and  extended  by  continuity  to  the  para-  and  peri-pancreatic 
tissue,  giving  rise  to  a  diffuse  and  acute  abscess.  The  termination 
is  sufficient  evidence  that  the  inflammation  was  produced  by  a  specific 
cause — the  pus  microbes.  In  the  second  case  the  primary  seat  of 
the  inflammation  was  the  same,  but  the  process  assumed  a  subacute 
character,  and  terminated  in  a  hyperplasia  of  the  connective  tissue. 
The  most  prominent  symptoms  in  both  cases  were  severe  pain  in 
the  epigastrium,  progressive  anaemia,  and  vomiting.  In  both  cases 
the  pain  assumed  a  neuralgic  character.      The  pain  was  referred  to 

1  Elements  of  Pathological  Anatomy,  Philadelphia,  1857. 

2  Delafield  and  Prudden,  Pathol.  Anat.  and  Histol.,  New  York,  1885,  p.  369, 


CHRONIC   INTERSTITIAL   PANCREATITIS.  351 

the  region  of  the  cceliac  plexus,  radiating  from  there  over  the  abdo- 
men. Neuralgia  of  the  cceliac  plexus  is  one  of  the  most  constant 
symptoms  of  disease  of  the  pancreas,  as  Klebs  alludes  to  it  as  being 
present  eleven  times  in  fifteen  uncomplicated  cases.  Atrophy  of  the 
cceliac  plexus  is  mentioned  by  Klebs  as  the  cause  of  the  neuralgia. 

A  high  degree  of  anaemia  was  apparent  in  both  cases  from  the 
extensive  area  of  tissue  which  was  found  in  an  cedematous  condition, 
as  well  as  from  the  statement  of  Mayo,  that  his  patient  presented 
the  appearance  of  a  person  who  had  suffered  from  repeated  and 
severe  haemorrhages.  As  the  pancreas  is  not  concerned  directly  in 
the  function  of  hpematogenesis,  we  can  only  explain  the  constancy 
with  which  this  symptom  is  mentioned  by  assuming  that  the  anaemia 
was  due  to  imperfect  digestion  and  assimilation,  caused  by  an  arrest 
of  pancreatic  secretion.  Vomiting  was  an  early  and  troublesome 
symptom  in  the  first  case,  but  appeared  only  toward  the  close  of  the 
disease  in  the  second  case.  No  reference  is  made  to  the  condition 
of  the  stools  in  either  case.  The  presence  of  undigested  fat  in  the 
stools  is,  however,  one  of  the  rare  symptoms  of  disease  of  the  pan- 
creas. Klebs  states  that  in  three  cases  where  this  symptom  was 
present,  the  ductus  Wirsungiani  was  either  entirely  or  partially 
obliterated,  while  in  a  number  of  cases  where  the  duct  was  in  the 
same  condition  the  stools  remained  normal. 

VII.    Chronic  Interstitial  Pancreatitis,  or  Sclerosis  of  the 

Pancreas. 

This  lesion  consists  in  an  increase  of  interstitial  connective 
tissue,  which  may  affect  the  entire  organ  or  remain  limited  to  some 
particular  portion,  more  especially  the  head  of  the  gland.  During 
the  early  stages  of  the  disease  the  organ  is  enlarged,  more  vascular 
and  firm,  while  later  the  cicatricial  contraction  of  the  interstitial 
deposit  produces  atrophy  of  the  parenchyma,  with  a  corresponding 
diminution  in  the  size  of  the  organ.  This  form  of  inflammation  of 
the  pancreas  is  of  particular  interest  to  the  surgeon,  as  the  cicatricial 
contraction  may  produce  secondary  changes  in  the  pancreatic  or  bile- 
dncts,  an  occurrence  which  would  indicate  a  resort  to  surgical 
measures  for  the  relief  of  immediate  symptoms  due  to  retention  of 
the  secretions. 

The  causes  which  produce  sclerosis  are  often  obscure,  but 
usually  referable!  to  an  antecedent  affection  in  some  of  the  organs 


352  EXPERIMENTAL   SURGERY. 

adjacent  to  the  pancreas,  as  the  peritoneum,  subperitoneal  tissue, 
duodenum,  the  common  bile-duct;  or  to  pancreatic  lithiasis,  where 
the  primary  cause  is  in  the  pancreas  itself.  The  connective  tissue 
proliferation  destroys  the  parenchyma  by  compression,  and  con- 
stitutes one  of  the  causes  of  stenosis  of  the  pancreatic  duct. 

Case  1.  Todd1  observed  this  condition  in  a  girl  fourteen  years  of  age,  in 
whom  the  head  of  the  pancreas  and  the  neighboring  connective  tissue  were 
the  seat  of  the  disease.  This  case  is  of  unusual  interest,  as  the  contraction  of 
the  cicatricial  tissue  produced  obstruction  of  the  common  bile-duct  by  com- 
pression, which  caused  a  dilatation  of  the  bile-ducts  behind  the  seat  of 
obstruction,  converting  them  into  a  large  sac,  which  was  located  behind  the 
duodenum  and  reached  downward  as  far  as  the  sacrum,  and  laterally  from  one 
kidney  to  the  other. 

Case  2.  0.  Wyss  2  gives  a  description  of  another  case  in  point.  A  man, 
fifty  years  of  age,  became  deeply  jaundiced  and  had  three  or  four  loose,  clay- 
colored  stools  daily.  He  died  after  an  illness  of  four  and  a  half  months' 
duration.  At  the  autopsy  the  liver  was  found  enlarged  and  of  a  deep  olive- 
green  color.  The  gall-bladder  and  bile-ducts  were  much  dilated  and  contained 
inspissated  bile.  The  common  bile-duct  entered  the  head  of  the  pancreas  four 
centimeters  before  its  termination  in  the  duodenum  and  traversed  the  indu- 
rated portion  of  the  organ  for  a  distance  of  two  and  a  half  centimeters.  At 
this  point  the  duct  was  found  so  much  contracted  that  only  a  fine  probe  could 
be  passed  through  it.  The  common  pancreatic  duct  was  dilated,  also  its 
branches,  which  at  some  points  were  dilated  in  the  form  of  cysts,  varying  in 
size  from  that  of  a  hempseed  to  that  of  a  hazelnut.  Wyss  attributed  dilatation 
of  the  common  duct  to  compression  by  one  of  the  smaller  cysts  in  the  head  of 
the  pancreas,  but  it  is  more  than  probable  that  the  dilatation  was  due  to  the 
cirrhotic  contraction  of  the  organ. 

Case  3.  That  icterus  is  not  a  constant  symptom  of  this  condition  is 
illustrated  by  the  following  case,  reported  by  Claessen:  A  man,  thirty  years  of 
age,  had  been  subject  to  indigestion,  constipation,  and  severe  pain  in  the 
episgastrium  for  several  years.  After  his  death,  it  was  shown  at  the  autopsy 
that  the  head  of  the  pancreas  and  the  acini  were  yellow,  and  the  inter-acinous 
connective  tissue  abundant,  and  yet  the  duct  of  Wirsung  and  the  bile  duct 
were  not  contracted. 

Remarks. — The  surgical  treatment  of  sclerosis  of  the  pancreas 
can  only  apply  to  secondary  lesions  which  result  from  stenosis  of 
the  pancreatic  or  bile-ducts,  and  distention  of  these  passages  by 
accumulations  of  the  secretions.  Such  an  occurrence  is  most  likely 
to  take  place  when  the  disease  affects  the  head  of  the  pancreas,  as 

1  Dublin  Hospital  Reports,  vol.  i. 

2  Virchow  and  Hirsch's  Jahresbericht. 


CHRONIC  INTERSTITIAL   PANCREATITIS.  353 

the  cicatricial  contraction  in  this  locality  may  cause  stenosis  of 
either  the  dnct  of  Wirsung,  the  common  bile-duct,  or  both.  Any 
operative  interference  in  these  cases  will  be  of  necessity  limited  to 
an  attempt  to  secure  an  artificial  outlet  for  the  retained  secretion. 
The  restoration  of  the  permeability  of  the  natural  outlet  by  any 
method  of  treatment  is  entirely  out  of  the  question. 

The  tendency  of  the  disease  is  to  aggravate  the  obstruction  as 
cicatricial  contraction  progresses.  The  history  of  all  these  cases 
pointed  to  an  impairment  of  digestion  as  the  principal  clinical 
feature  in  each  instance.  It  is,  therefore,  of  considerable  importance 
to  examine  carefully  into  every  obstinate  and  obscure  case  of  indi- 
gestion, with  a  view  to  eliminate  the  possibility  of  organic  disease 
of  the  pancreas  as  the  cause  of  the  derangement  of  digestion.  In 
cases  of  permanent  retention  of  the  bile  or  the  pancreatic  juice 
caused  by  cicatricial  compression  of  the  bile-duct  or  the  pancreatic 
duct,  the  earlier  symptoms  will  have  reference  to  a  history  of 
obstinate  indigestion,  progressive  in  its  character.  If,  on  the  other 
hand,  the  obstruction  is  produced  by  the  impaction  of  a  calculus,  the 
previous  history  points  to  attacks  of  sudden  and  severe  pain,  and 
other  symptoms  indicative  of  the  passage  of  a  calculus  along  the 
excretory  duct. 

In  case  of  biliary  retention  cysts,  as  represented  in  case  1,  the 
establishment  of  an  external  biliary  fistula  would  result  in  a  perma- 
nent fistula,  as  the  impermeability  of  the  bile-duct  would  preclude 
the  possibility  of  reestablishing,  by  an  attempt  of  any  kind,  the 
normal  communication  between  the  dilated  bile  passages  and  the 
intestine.  Such  an  operation  would  remove  only  the  urgent  symp- 
toms due  to  retention  and  absorption  of  bile,  but  would  leave 
unchanged  the  primary  cause  of  the  retention,  and  would  exclude, 
permanently,  the  bile  as  a  digestive  fluid  from  the  alimentary  canal. 

As  the  obstruction  is  permanent  and  irremediable,  the  operation 
which  suggests  itself  as  fulfilling  the  urgent  indications,  as  well  as 
preventing  remote  ill  consequences,  is  the  formation  of  a  new  outlet 
for  the  bile  into  the  intestinal  canal,  by  establishing  a  permanent 
fistula  between  the  duodenum  and  the  gall-bladder,  or  between  the 
duodenum  and  the  dilated  bile-ducts.  Duodeno-cholecystostomy 
has  a  future  in  all  cases  of  permanent  and  incurable  obstructive 
lesions  in  the  l.ilc  duct,  and  will  become  an  established  operation  ;is 
soon  as  it  has  been  perfected  by  an  improved  technique. 


354  EXPERIMENTAL   SURGERY. 

My  experiments  on  animals  have  demonstrated  that  physio- 
logical detachment  of  any  portion  of  the  pancreas  is  invariably 
followed  by  degeneration  and  atrophy,  irrespective  of  the  particular 
method  by  which  this  detachment  is  effected ;  consequently  it  is  only 
reasonable  to  assume  that  permanent  obliteration  of  the  pancreatic 
duct  by  cicatricial  contraction  is  always  followed  by  degeneration  of 
the  parenchyma  of  the  gland  on  the  distal  side  of  the  seat  of 
obstruction. 

It  is  on  this  account  that  stenosis  of  the  pancreatic  duct  is 
seldom  followed  by  dilatation  of  the  duct  to  any  considerable  extent 
on  the  distal  side  of  the  constriction,  and  even  more  seldom  by  the 
formation  of  a  cyst.  A  retention  cyst  can  result  from  obstruction 
only  so  long  as  secretion  has  not  been  entirely  suspended,  and  when, 
at  the  same  time,  absorption  of  the  pancreatic  juice  does  not  take 
place,  on  account  of  further  extensive  pathological  changes  in  the 
structures  which  perform  this  function  when  the  gland  is  otherwise 
in  a  normal  condition. 

As  the  physiological  detachment  by  obstruction  of  the  common 
pancreatic  duct  caused  by  cicatricial  contraction  is  invariably 
followed  by  complete  destruction  of  the  parenchyma  of  the  con- 
tributory portion  of  the  gland,  it  is  evident  that  the  surgical 
treatment  of  a  cyst  of  the  pancreas  in  such  cases  can  be  indicated 
only  when  the  swelling  becomes,  in  itself,  a  source  of  serious  incon- 
venience and  pain.  The  proper  treatment  in  all  such  cases  consists 
in  the  formation  of  an  external  pancreatic  fistula  by  abdominal 
section.  There  is  no  danger,  in  such  instances,  of  the  fistula 
remaining  permanent,  as  the  glandular  tissue  which  might  remain  at 
the  time  of  operation  will,  in  the  course  of  time,  disappear  by 
degeneration  and  absorption.  As  in  animals,  so  in  man,  the  health 
of  the  individual  after  gradual  atrophy  of  the  pancreas  will  depend 
upon  the  physiological  capacity  of  vicarious  organs,  in  each  par- 
ticular case,  to  assume  the  functions  of  the  pancreas. 

In  recapitulation,  it  may  be  stated  that  cirrhosis  or  chronic 
interstitial  pancreatitis  sometimes  produces  stenosis  of  the  bile-duct 
or  the  pancreatic  duct,  and  that,  when  the  obstruction  is  followed  by 
retention  of  the  secretions,  an  operation  becomes  always  necessary 
in  biliary  retention,  which  should  be  treated  by  establishing  a  new 
outlet  for  the  bile  into  the  duodenum;  while  the  formation  of  an 
external  pancreatic  fistula  in  cases  of  cyst  of  the  pancreas,  becomes 


GANGRENE    OF   THE   PANCREAS.  355 

necessary  only  when  the  presence  of  the  swelling  in  itself  has 
become  a  source  of  sufficient  pain  and  discomfort  to  warrant  treat- 
ment by  abdominal  section. 

VIII.    Gangrene  of  the  Pancreas. 

* 

One  of  the  terminations  of  acute  inflammation  of  the  pancreas 
is  gangrene.  Cases  have  been  reported  where  spontaneous  recovery 
followed  elimination  of  the  necrosed  organ  through  the  alimentary 
canal.  If  spontaneous  recovery  in  this  condition  is  possible,  it 
would  seem  plausible  that  a  timely  removal  of  the  necrosed  organ 
by  surgical  interference  would  add  to  the  chances  of  recovery; 
consequently  we  shall  add  gangrene  to  those  diseases  of  the  pan- 
creas which  should  be  treated  by  operative  measures. 

Case  1.  Trafoyer,  of  Hernals,  treated  a  patient  suffering  from  what 
appeared  to  be  a  passage  of  gall-stones.  During  the  course  of  the  disease 
the  patient  passed,  per  rectum,  a  solid  mass,  the  nature  of  which  could  not  be 
readily  ascertained.  This  mass  was  sent  for  examination  to  Rokitansky,  who 
found  in  it  gall-stones  and  a  large  part  of  the  pancreas  in  which  the  duct  was 
plainly  visible.  Rokitansky  believed  that  a  portion  of  the  pancreas  had 
become  invaginated  into  the  duodenum  and  had  sloughed.  Nothing  could  be 
ascertained  concerning  the  subsequent  history  of  the  case.1 

Case  2.  Reported  by  Chiari.2  Female,  aged  forty-six  years,  who  had 
been  subject  to  occasional  attacks  of  pain  in  the  stomach.  She  was  seized 
suddenly  with  severe  pain  in  the  abdomen,  followed  by  vomiting  and  other 
symptoms  of  diffuse  peritonitis.  Toward  the  close  of  the  disease  she  had  a 
chill,  and  vomited  a  black,  very  offensive  fluid.  At  the  necropsy  the  pancreas 
was  found  separated  from  all  its  attachments  and  of  a  brownish  color.  The 
duodenum  and  transverse  mesocolon  were  perforated;  the  bursa  omentalis 
contained  an  offensive  sanious  fluid,  consecutive  to  diffuse  peritonitis.  The 
pancreatico-duodenal  artery  was  eroded. 

Case  3.3  Patient,  a  man  thirty-eight  years  of  age,  was  attacked  with 
symptoms  indicative  of  cholelithiasis,  followed  by  symptoms  of  obstruction 
of  the  bowels,  which  lasted  for  a  number  of  days,  and  subsided  only  after  the 
passage,  per  rectum,  of  the  greater  portion  of  the  necrosed  pancreas.  The 
patient  recovered. 

Case  4.  Israel  reports  a  case  of  necrosis  of  the  pancreas  in  a  patient 
suffering  from  diabetes  mellitus.4  The  autopsy  showed  a  fluctuating  tumor 
between  the  stomach  and  transverse  colon,  which  revealed  itself  as  a  cyst,  with 

1  Allgem.  Wiener  Zeitung,  No.  29,  1862. 

-  Wiener  Med.  Wochenschrift,  Nos.  6  and  7,  1881. 

:i  Ibid. 

4  Virchow's  Archiv,  vol.  lxxxiii.  p.  181. 


356  EXPERIMENTAL   SURGERY. 

thick  walls  firmly  adherent  to  the  intact  head  of  the  pancreas.  The  cyst  con- 
tained 300  cubic  centimeters  of  a  clay-colored  fluid,  in  which  crystals  of  haema- 
todin  and  the  necrosed  body  and  tail  of  the  pancreas  were  found.  Israel 
attributes  the  cause  of  the  destructive  process  to  an  inflammation  of  the 
peripancreatic  tissue,  which  had  given  rise  to  repeated  haemorrhages  into  and 
around  the  pancreas.  The  disease  of  the  pancreas,  he  holds,  was  not  the 
cause,  but  the  effect  of  the  diabetes. 

Case  5.  Prince1  reports  the  following  case:  A  man,  twenty-two  years  of 
age,  during  a  violent  exertion,  was  taken  with  severe  pain  in  the  abdomen, 
followed  by  pain  in  the  epigastric  region,  vomiting,  chills,  and  a  sensation  of 
great  oppression  and  uneasiness.  In  a  few  days  diarrhoea  followed,  and 
during  the  third  week  he  died.  At  the  autopsy  the  anterior  abdominal  wall 
was  found  firmly  adherent  to  the  omentum  and  intestines;  between  the 
intestinal  convolutions  a  chocolate-colored  fluid  was  found.  The  greater 
portion  of  the  pancreas  was  destroyed  and  converted  into  a  black  gangrenous 
mass.  The  mesentery  of  the  upper  portion  of  the  jejunum,  which  was 
adherent  to  the  lower  margin  of  the  transverse  colon,  showed  in  its  folds  an 
accumulation  of  thick  greenish  pus. 

Case  6.  Reported  by  Rosenbach.2  A  woman,  fifty-seven  years  of  age, 
otherwise  in  good  health,  had  suffered  some  time  before  from  pain  in  the  abdo- 
men and  constipation,  but  was  soon  relieved.  Three  weeks  before  she  came 
under  observation  of  the  reporter,  the  same  trouble  returned.  The  bowels  had 
not  moved  for  three  days;  frequent  vomiting  of  greenish  fluid;  great  weakness. 
On  examination,  a  fluctuating  tumor  the  size  of  a  child's  head  was  detected  in 
the  epigastric  region,  behind  the  stomach  which  was  considerably  dilated. 
The  tumor  was  immovable.  As  the  symptoms  pointed  to  intestinal  obstruc- 
tion of  some  kind,  and  failed  to  be  relieved  by  enemata,  it  was  decided  to 
perform  laparotomy,  to  which  the  patient  readily  consented.  The  abdomen 
was  opened  through  the  median  line,  but,  as  the  tumor  was  not  rendered  suffi- 
ciently accessible,  a  transverse  incision  was  made  over  the  most  prominent 
part.  After  division  of  the  mesocolon  an  effort  was  made  to  enucleate  the 
tumor,  but  the  inflammatory  adhesions  were  so  firm  that  the  attempt  had  to 
be  abandoned.  An  effort  was  then  made  to  push  the  stomach  upward,  but 
this  likewise  failed.  During  these  manipulations  the  tumor  ruptured  and  at 
first  clear,  then  turbid  offensive  fluid  poured  out.  The  fluid  was  removed 
without  soiling  the  peritoneal  cavity.  The  sac  was  then  stitched  to  the  mar- 
gins of  the  wound.  After  suturing  the  remaining  portion  of  the  external 
incision  the  opening  in  the  sac  was  enlarged  and  drained.  The  patient  died  of 
shock  six  hours  after  the  operation.  At  the  autopsy  the  necrosed  pancreas 
was  found  in  the  sac.  The  abscess  cavity  extended  behind  the  stomach  and 
lesser  omentum.  The  intestinal  obstruction  was  caused  by  pressure  of  the 
swelling  upon  the  small  intestine.  ' 

1  Pancreatic  Apoplexy,  with  a  Report  of  Two  Cases,  Boston  Med.  and 
Surg.  Journ.,  July  13  and  20,  1883. 

2  Centralblatt  fur  Chirurgie,  1882. 


ABSCESS   OF   THE  PANCREAS.  357 

Remarks. — The  pancreas  may  constitute  one  of  the  component 
parts  of  the  intussusceptum  in  cases  of  invagination  of  the  bowels, 
as  such  a  case  has  been  reported  by  Bandl,  and  the  specimen  exam- 
ined by  Rokitansky  furnishes  a  similar  illustration.  The  second 
case  reported  by  Chiari  may  have  been  of  a  similar  nature,  the  invagi- 
nated  portion  having  sloughed  with  the  remaining  portion  of  the 
intussuscepturn,  leaving  the  continuity  of  the  bowel  unimpaired  by 
adhesions  at  the  point  of  separation.  If,  in  this  instance,  the 
necrosis  was  due  to  inflammation,  we  can  only  infer  that  the  para- 
pancreatic  abscess  ruptured  into  the  bowel,  and  that  the  necrosed 
portion  of  the  pancreas  was  eliminated  in  this  manner,  and  that 
subsequently  the  opening  in  the  bowel  was  closed.  Constipation 
was  a  prominent  symptom  in  a  number  of  these  cases,  and  in  Rosen- 
bach's  case  the  symptoms  of  obstruction  were  so  well  marked  that  it 
was  decided  to  perform  laparotomy  for  its  relief.  This  last  case  is 
also  of  great  interest,  as  the  existence  of  a  tumor  in  the  region  of 
the  pancreas  was  diagnosticated  during  life. 

Modern  surgery  deals  extensively  with  abdominal  section  for 
the  relief  and  cure  of  peritonitis  and  intestinal  obstruction.  In 
searching  for  the  cause  of  either  of  these  conditions  during  lapar- 
otomy, the  pancreas  should  not  be  forgotten,  and  when  it  is  found 
that  the  primary  disease  is  located  in  or  around  this  organ,  radical 
measures  should  be  adopted  whenever  such  a  course  appears  prac- 
ticable. 

Whenever  the  sac  can  be  stitched  to  the  external  incision,  this 
should  be  done,  and  the  sac  opened,  disinfected,  and  drained. 
Search  should  be  made  for  the  necrosed  pancreas,  and  when  fo^^nd 
detached,  it  should  be  removed.  As  in  most  of  these  cases  the 
retroperitoneal  tissue  is  extensively  infiltrated,  a  counter-opening 
should  be  made  in  the  lumbar  region  above  the  kidney,  and  thorough 
drainage  established.  If  an  anterior  abdominal  fistula  cannot  be 
established,  the  course  to  be  pursued  should  be  the  same  as  in  treat- 
ing a  pancreatic  abscess  under  similar  conditions. 

IX.    Abscess  of  the  Pancreas. 

At  the  present  time  no  one  familiar  with  the  recent  advances  in 
surgery  would  question  the  propriety  of  treating  a  suppurating 
cavity  by  incision  ami  drainage,  wherever  it  might  be  located.  Some 
of  the    most    valuable    recent    contributions    to    surgical    literature 


358  EXPERIMENTAL   SURGERY. 

describe  improved  methods  in  treating  deep-seated  abscesses.  Asepsis 
and  effective  drainage  are  the  two  cardinal  points  upon  which  we 
have  learned  to  depend  in  the  treatment  of  abscesses  in  important 
organs  or  cavities.  If  we  can  secure  and  maintain  these  two  essen- 
tial conditions,  we  can  attack  with  immunity  and  a  fair  hope  of 
success,  any  abscess,  wherever  it  may  be  located,  and  whatever  its 
immediate  surroundings  may  be. 

In  looking  over  the  literature  on  abscesses  of  the  abdominal 
organs,  we  find  that  modern  surgery  has  been  guided  almost 
exclusively  by  the  teaching  of  the  old  master :  Ubi  pus — ibi  evacuo. 
It  is  somewhat  surprising  that  abscess  of  the  pancreas  has  never 
been  made  the  subject  of  surgical  treatment.  The  two  principal 
reasons  for  this  may  be  found  in  the  facts  that  abscess  of  the 
pancreas  is  of  rare  occurrence,  and  that  the  recognition  of  the  lesion, 
when  it  does  exist,  is  surrounded  by  many  difficulties.  There  can 
be  no  doubt,  however,  that  in  the  near  future,  abscess  of  the  pan- 
creas will  be  treated  on  the  same  principles  as  suppuration  in  any 
other  locality. 

The  remote  location  of  the  abscess  may  offer  many  serious 
obstacles  to  diagnosis  and  a  rational  course  of  treatment;  but  these 
difficulties  will  be  overcome  by  improved  methods  of  examination, 
and  more  perfect  methods  of  operation.  As  suppuration  is  only  one 
of  the  terminations  of  inflammation,  abscess,  like  inflammation,  may 
occur  primarily  in  the  gland  itself,  or  it  may  commence  -in  the  para- 
or  peri -pancreatic  tissue.  If  the  abscess  is  endo -pancreatic,  it  may 
be  bounded  and  circumscribed  by  the  proper  investment  of  the 
gland;  if,  on  the  other  hand,  it  commences  primarily  outside  of 
the  gland,  it  appears  as  a  diffuse  abscess,  which  extends  to  the 
pancreas  by  contiguity:  in  other  words,  we  speak  of  the  abscess 
as  a  suppurative  pancreatitis,  or  a  suppurative  peri-  or  para- 
pancreatitis. 

Case  1.  Frison l  reports  a  case  of  abscess  of  the  pancreas  following 
suppurative  pancreatitis,  where  the  collection  of  pus  did  not  extend  beyond 
the  limits  of  the  gland.  An  otherwise  healthy  mulatto,  twenty-eight  years  of 
age,  farmer,  was  attacked  in  Jane,  1873,  by  icterus  with  no  fever.  Appetite 
diminished.  The  symptoms  were  not  of  sufficient  severity  to  keep  him  from 
his  work.  In  August  he  complained  of  pain  in  the  right  hypochondriac 
region,  which  was  soon  followed  by  ascites  and  oedema  of  legs  and  scrotum. 

1  Pancreatite  suppuree.  Recueil  de  mem.  de  med.  mil.,  Mai,  Juin,  187fi. 


ABSCESS   OF   THE   PANCREAS.  359 

He  was  troubled  at  this  time  by  an  intense  thirst,  and  voided  large  quantities 
of  urine,  which,  on  examination,  was  found  to  contain  sugar.  The  livei  was 
enlarged  and  the  patient  emaciated  rapidly.  No  fever  or  diarrhoea.  Stools 
clay  colored.  Appetite  gradually  declined,  and  the  patient  died  in  a  state  of 
advanced  marasmus.  At  the  autopsy  the  intestines  and  stomach  were  found 
normal.  The  pancreas  was  enlarged  to  three  times  its  normal  size  and  infil- 
trated with  pus;  the  splenic  end  was  distended  by  a  large  abscess.  Gall-bladder 
and  bile-ducts  greatly  distended.  Liver  olive  green  in  color  and  contained 
three  abscesses,  but  was  otherwise  healthy  in  structure. 

Remarks. — la  this  case  the  symptoms  during  life  pointed  to  the 
liver  as  the  seat  of  the  disease.  The  jaundice  was  undoubtedly  pro- 
duced by  stenosis  of  the  bile-duct,  either  by  a  catarrhal  inflammation 
of  the  duct  itself,  or  compression  of  the  duct  by  the  inflammatory 
exudation  which  attended  the  acute  inflammation  of  the  pancreas. 
The  ascites  was  more  likely  the  result  of  an  inflammation  of  the 
peritoneum  overlying  the  pancreas,  than  of  an  obstruction  to  the 
portal  circulation.  The  suppuration  in  the  pancreas  was  not 
attended  by  an  increase  of  temperature.  The  diabetes  was  probably 
due  to  the  disease  of  the  pancreas,  and  was  not  a  coincident  affec- 
tion, as  a  number  of  cases  of  diabetes  have  been  reported  which 
occurred  in  the  course  of  some  disease  of  this  organ. 

Case  2.  Timoteo  Riboli '  reports  the  case  of  a  woman,  aged  fifty-seven 
years,  who  suffered  from  impairment  of  digestion,  loss  of  appetite,  emaciation, 
and  attacks  of  vomiting  in  the  forenoon.  The  tongue  was  coated.  No  fever, 
but  night  sweats.  Bismuth  and  magnesia  improved  the  symptoms  for  a  time, 
but  soon  the  disease  became  aggravated.  Hepatitis  was  diagnosticated,  inas- 
much as  the  patient  became  icteric  and  complained  of  a  deeply  seated  dull 
pain  in  the  region  of  the  liver  and  epigastrium.  Among  a  number  of  col- 
leagues who  saw  the  case  in  consultation,  Tommasini  was  the  only  one  who 
believed  that  the  pancreas  was  the  seat  of  the  disease.  The  patient  was 
emaciated  to  a  skeleton  and  died  of  inanition.  At  the  autopsy  the  pancreas 
was  found  distended  with  pus.  Gall-bladder  was  distended  with  bile.  Liver 
congested.  No  other  pathological  conditions  were  found  which  might  serve 
to  explain  the  cause  of  death. 

Remarks.  The  course  of  the  disease  in  this  case  was  again 
afebrile.  The  symptoms  simulated  disease  of  the  liver  even  more 
closely  than  in  the  preceding  case,  as  no  mention  is  made  of  the 
presence  of  sugar  in  the  urine.     The  suppuration  did  not  extend 

into  the  parapancn-atic  space. 

1  Schmidt's  Jahrbttoher,  L869,  2,  p.  177. 


360  EXPERIMENTAL  SURGERY. 

Case  3.  The  following  case  is  described  by  Dr.  James  Kilgour:1  The 
patient  was  a  man,  forty-one  years  of  age,  who  was  treated  for  several  years 
for  what  was  termed  bilious  dyspepsia.  In  March,  1850,  when  first  seen  by  the 
reporter,  he  was  considerably  emaciated  and  of  a  melancholic  disposition.  A 
prominent  symptom  was  vomiting,  especially  in  the  morning,  and  about  two 
hours  after  meals.  The  matter  vomited  was  a  sour,  viscid  fluid,  varying  in 
quantity  from  an  ounce  to  a  quart.  Skin  dry  and  of  a  yellowish  hue.  No 
diarrhoea,  and  the  stools  contained  no  bile.  Urine  of  sp.  gr.  1.022,  normal  in 
quantity,  loaded  with  urates,  and  contained  some  fat.  Pulse  small,  100.  No 
pain  in  abdomen.  On  left  side,  from  border  of  stomach  to  crest  of  ilium, 
abdomen  was  dull  on  percussion;  on  palpation  inelastic,  nodulated,  and  of  a 
doughy  feel.  The  area  of  swelling  was  not  well  defined.  Neither  fluctuation 
nor  pulsation  could  be  felt.  During  the  middle  of  the  month  of  May,  the 
patient  complained  of  chilly  sensations,  and  the  area  of  dullness  increased 
toward  the  left.  Toward  the  end  of  the  month  the  chills  disappeared  and  the 
abdomen  became  tender  and  elastic  above.  During  the  latter  part  of  July, 
the  legs  became  cedematous  and  the  patient  was  somewhat  delirious.  Toward 
the  close  of  the  disease  he  was  again  attacked  by  a  number  of  chills  and  died 
July  28th. 

The  autopsy  revealed  the  stomach  distended  with  gas,  its  walls  very  thin; 
pylorus  indurated  and  slightly  narrowed.  Duodenum  softened  by  inflamma- 
tion, the  portion  near  the  pancreas  being  converted  into  a  pultaceous  mass. 
Liver  normal.  Spleen  enlarged  one-third.  Pancreas  enlarged  to  the  size  of  a 
teacup,  its  left  end  being  attached  to  the  suprarenal  capsule  on  same  side. 
On  incising  the  pancreas  a  milky  fluid  escaped.  The  entire  gland  was  con- 
verted into  a  single  sac,  which  contained  purulent  fluid  with  some  cheesy 
particles  and  fragments  of  cellular  tissue. 

Remaeks. — In  this  case  the  symptoms  were  sufficiently  clear  to 
enable  an  accurate  observer  at  the  present  time  to  have  made  a  prob- 
able diagnosis  of  abscess  of  the  pancreas.  The  obstinate  vomiting, 
with  the  absence  of  signs  of  disease  of  the  liver,  and  the  progressive 
emaciation,  should  have  led  at  least  to  a  suspicion  of  disease  of  the 
pancreas. 

The  location  of  the  tumor  was  also  suggestive  of  the  primary 
starting  point  of  the  swelling.  The  abscess  cavity  was  larger  than 
in  the  preceding  cases,  and  the  presence  of  pus  was  also  suggested 
by  the  chills  which  were  present  at  the  beginning  and  close  of  the 
disease.  As  the  abscess  cavity  was  single,  this  would  have  been  a 
proper  case  for  surgical  treatment.  A  somewhat  uncommon  feature 
in  this  case  was  the  almost  complete  absence  of  pain,  a  symptom 
which  has  been  considered  by  Claessen  characteristic  of  disease  of 

1  London  Journal,  Nov.  1850. 


ABSCESS   OF   THE  PANCREAS.  361 

the  pancreas.     The  character  of  the  fluid  in  the  cyst  would  indicate 
that  it  was  a  mixture  of  pus  and  pancreatic  juice. 

As  in  other  secretory  organs,  the  suppurative  process  may 
commence  in  the  duct  and  extend  to  the  interstitial  connective  tissue 
by  continuity.  This  is  the  manner  in  which  the  presence  of  foreign 
bodies,  such  as  parasites  or  calculi  in  the  duct,  gives  rise  to  abscess 
of  the  pancreas.  In  the  following  case  the  inflammation  of  the  duct 
and  the  consecutive  interstitial  suppurative  pancreatitis  were 
atttibuted  to  the  presence  of  an  intestinal  worm: 

Case  4.  Reported  by  Shea.1  The  patient  was  a  woman,  aged  twenty-nine 
years,  who  complained  of  abdominal  pain,  and  was  jaundiced.  After  a  few 
days,  she  improved  under  a  mild  alkaline  treatment,  but  about  three  weeks 
subsequently  again  became  worse.  The  pain  was  in  the  region  of  the  pan- 
creas. At  the  same  time  she  suffered  from  nausea  followed  by  vomiting; 
jaundice  reappeared.  Active  treatment  was  resorted  to,  but  she  soon  became 
unconscious  and  died  forty-eight  hours  subsequently.  The  necropsy  showed 
that  the  body  was  fairly  nourished  and  distinctly  jaundiced.  The  lungs  were 
slightly  congested  at  the  base.  Liver  large,  pale,  and  soft.  Pancreas  enlarged 
and  hard,  being  the  seat  of  an  abscess  containing  pus.  A  round  worm,  seven 
inches  long,  was  found  folded  upon  itself,  lying  in  and  obstructing  the  pan- 
creatic duct,  the  larger  portion  of  the  worm  being  in  the  duodenum.  The 
intestines  were  healthy.  In  the  absence  of  any  other  disease,  death  in  this 
instance  must  have  resulted  from  inflammation  of  the  duct  and  parenchyma 
of  the  pancreas,  by  the  irritation  induced  by  the  presence  of  the  worm.  The 
jaundice  was  undoubtedly  produced  by  the  same  cause. 

Remarks. — Positive  evidence  is  wanting  in  this  case  to  prove 
that  the  suppuration  was  caused  by  the  presence  of  the  parasite,  as 
the  worm  might  have  entered  the  pancreatic  duct  after  death.  We 
have  evidence  that  in  many  cases  ascarides  have  been  found  in  the 
ductus  pancreaticus,  without  the  presence  of  abscess  or  even  inflam- 
mation. Davaine"  relates  that  he  has  found  them  present  in  this 
locality  in  four  cases,  and  in  none  of  them  had  secondary  inflamma- 
tory changes  taken  place.  Klebs  found  six  worms  in  one  case,  four 
in  the  head,  and  two  in  the  tail  of  the  pancreas. 

Cask  ~>.  Mayo  refers  to  a  case  that  came  under  the  observation  of 
Percival/1  The  patient  was  a  gentleman  who  had  jaundice  and  bilious  vomit- 
ing. A  tumor  appeared  at  the  epigastrium;  his  strength  failed,  blood  and 
fetid    pus  were  discharged  by  stool,  and  he  died  exhausted  in  three  months. 

1  The  Lancet,  November  5,  1881. 

2  Trait.'  dee  Entoz.,  p.  116. 

Outlines  Of  Human  Pathology,  London,  1H:;<'»,  p.  •(()«.». 


362  EXPERIMENTAL   SURGERY. 

At  the  necropsy  the  pancreas  was   found  greatly  enlarged,  and  contained  a 
considerable  abscess;  the  ductus  communis  was  obliterated  by  the  pressure. 

The  class  of  cases  which  are  of  special  importance  and  interest 
to  the  surgeon  are  those  diffuse  abscesses  which  take  their  origin  in 
the  parapancreatic  connective  tissue:  extensive  collections  of  pus  as 
we  observe  them  in  cases  of  parapancreatitis  purulenta.  As  the 
glandular  tissue  is  not  primarily  affected  in  these  cases,  early 
evacuation  and  drainage  of  the  abscess  cavity  would  not  only 
preserve  the  anatomical  and  functional  integrity  of  the  gland,  but 
would  also  serve  as  a  life-saving  measure  by  securing  an  early 
outlet  of  the  abscess  contents. 

The  case  reported  by  Haller  and  Klob,  and  referred  to  under 
the  head  of  pancreatitis,  case  1,  furnishes  a  good  illustration  of 
cases  belonging  to  this  class. 

Case  6.  An  interesting  case  of  abscess  of  the  pancreas  has  recently  been 
reported  by  Musser.1  The  patient  was  a  male,  aged  forty-two,  shoemaker, 
who  was  admitted  to  the  wards  of  the  Presbyterian  Hospital,  May  12,  1885, 
and  died  June  6th  following.  He  was  of  intemperate  habits,  but  his  general 
health  had  always  been  good.  His  poverty  had  exposed  him  to  all  kinds  of 
hardships.  The  duration  of  the  present  illness  was  not  known,  but  from  his 
statements  it  was  ascertained  that  his  health  had  been  failing  all  the  spring. 
He  had  never  received  any  injury.  He  was  considerably  emaciated.  He 
vomited  only  once,  and  that  was  on  the  day  of  admission.  Marked  ascites 
was  observed,  but  nothing  else  could  be  found.  He  remained  in  a  stupid  con- 
dition, took  but  little  food,  and  manifested  no  signs  of  pain.  No  fever,  no 
sweating.  Palpation  showed  the  liver  and  spleen  to  be  normal,  while  an  ill- 
defined  tumor  could  be  felt  in  the  epigastric  region.  Urine  contained  a  trace 
of  albumen,  but  no  casts.  The  ascites  was  so  great  as  to  warrant  tapping, 
and  this  was  accordingly  done.  The  abdomen  was  thirty-six  inches  in 
circumference  at  the  umbilicus  before  tapping.  Within  eighteen  hours  after 
tapping,  it  had  filled  entirely,  and  in  twenty-four  hours  measured  thirty-two 
and  a  half  inches.     He  died  of  exhaustion. 

After  death,  by  palpation,  a  fixed  mass  was  detected  in  the  abdomen, 
extending  from  the  right  mammary  line,  one  inch  above  the  umbilical  line, 
directly  across  to  the  corresponding  line  on  the  left  side.  Its  upper  margin 
was  not  well  defined,  but  it  appeared  to  be  two  inches  wide.  The  abdomen 
was  filled  with  serum  in  which  some  lymph  floated.  The  intestines  were  matted 
together  by  recent  lymph.  The  peritoneum  showed  signs  of  inflammation. 
Corresponding  to  the  position  of  the  mass  indicated  by  palpation,  the  omentum 
was  found  matted  together,  with  its  inferior  border  turned  upward,  and  lying 
across  the  stomach.     This  organ  was  fixed  and  dilated,  its  inferior  border 

1  American  Journal  of  the  Medical  Sciences,  April,  1886,  p.  449. 


ABSCESS   OF   THE   PANCREAS.  363 

extending  to  the  umbilicus.  The  liver  occupied  its  normal  position.  The 
transverse  colon  extended  across  the  abdomen  along  the  lower  margin  of  the 
stomach,  thus  permitting  the  omentum  to  occupy  the  position  indicated 
above.  Further  study  of  the  relations  of  the  abdominal  organs  revealed  the 
formation  of  a  large  cavity  containing  about  a  quart  of  pus.  This  cavity 
was  formed  by  the  posterior  wall  of  the  stomach  in  front,  by  the  pancreas, 
duodenum,  and  transverse  colon  below,  and  by  an  extension,  or  rather  disten- 
tion, of  the  peritoneum  above  and  behind.  Certainly  the  pus  did  not  fill  the 
retroperitoneal  space  or  extend  into  it,  and  was  not  in  close  apposition  to  the 
diaphragm  or  brim.  It  was  situated  in  the  duodeno-jejunal  fossa.  Adhesions 
prevented  communication  with  the  abdominal  cavity  and  the  retroperitoneal 
space.  This  abscess  cavity  communicated  with  an  abscess  the  size  of  an 
orange,  situated  in  the  head  of  the  pancreas,  its  point  of  rupture  into  the 
duodeno-jejunal  fossa  being  in  the  middle  and  upper  part. 

The  remainder  of  the  pancreas  was  made  up  of  dense  connective  tissue, 
throughout  which  there  were  innumerable  pus  pookets,  varying  from  a  pea  to 
pecan  nut  in  size.  The  secreting  tissue  of  the  organ  was  not  discernible  to  the 
naked  eye.  The  ducts  were  not  occluded,  but  rather  dilated,  and  no  calculi 
were  found.  The  portal  vein  was  filled  with  a  purulent  thrombus.  The  splenic 
vein  was  also  partially  closed  by  a  soft  thrombus.  The  superior  and  inferior 
mesenteric  veins  were  completely  blocked  by  laminated  thrombi,  which  were 
firmly  adherent  to  their  walls.  On  microscopical  examination,  the  pancreas 
was  found  to  be  made  up  of  old  and  young  connective  tissue;  in  the  large 
interstices  of  the  bundles  of  old  tissue,  the  glandular  structure  could  be 
readily  made  out.  while  the  tubules  were  seen  to  be  in  a  state  of  catarrhal 
inflammation.  The  intertubular  connective  tissue  was  crowded  with  young 
cells. 

Remarks. — In  this  case  the  conditions  were  favorable  for 
successful  treatment  by  abdominal  section,  had  even  a  probable 
diagnosis  been  made  before  the  extensive  and  serious  complication 
of  thrombo-phlebitis  occurred.  The  symptoms  during  life  simulated 
cirrhosis  of  the  liver  so  closely  that  it  was  impossible  to  differentiate 
between  this  affection  and  disease  of  the  pancreas,  although  an 
ill-defined  tumor  could  be  felt  in  the  epigastric  region.  In  similar 
cases  an  exploratory  laparotomy  should  be  done  for  the  purpose  of 
making  a  positive  diagnosis,  and,  when  similar  favorable  conditions 
are  found,  it  could  be  followed  at  once  by  radical  measures,  with  a 
view  of  securing  evacuation  and  drainage  of  the  abscess  cavity.  In 
this  case  the  abscesses  in  the  viscus  were  the  result  of  a  purulent 
pancreatitis;  the  secondary  abscess  was  the  result  of  perforation 
into  the  duodenojejunal  fossa,  followed  by  suppurative  peri  pan 
creatitis. 


364  EXPERIMENTAL  SURGERY. 

I.    Pathology  of  Abscess  of  the  Pancreas. 

Recent  investigations  have  shown  the  existence  of  a  direct 
causative  relation  between  the  pus  microbes  and  suppuration;  hence 
we  must  take  it  for  granted  that  every  purulent  pancreatitis,  peri- 
pancreatitis, or  parapancreatitis  is  caused  by  the  presence  of  these 
germs  in  the  tissues.  In  case  there  is  no  direct  invasion,  by  a  loss 
of  continuity,  of  the  hollow  viscera  in  the  vicinity  of  the  pancreas, 
or  no  direct  communication  with  the  external  air  by  a  penetrating 
wound,  we  must  assume  that  the  germs  reach  the  gland  through  the 
circulation,  and  find  a  favorable  soil  prepared  by  some  antecedent 
pathological  change.  Such  conditions  may  be  determined  by  contu- 
sion of  the  organ,  disturbance  of  the  capillary  circulation  by  various 
causes,  or  thrombo -phlebitis.  Norman  Moore  reports  the  case  of  a 
female,  twenty- seven  years  of  age,  who  had  died  of  pyophlebitis,  and 
in  which,  on  post-mortem  examination,  beside  the  portal,  splenic,  and 
vena  azygos  minor  veins,  the  pancreatic  veins  were  also  blocked  by 
decolorized  and  adherent  thrombi.1 

The  same  author  gives  an  account  of  two  cases  of  abscess 
of  the  pancreas  due  to  plugging  of  the  pancreatic  vessels. 2  He 
remarks:  "Pathologically,  the  case  in  which  thrombosis  of  the 
pancreas  was  found  is  interesting  as  indicating  how  pancreatic 
abscess  is  produced.  The  much  commoner  condition  of  the  liver  in 
the  other  cases  shows  that,  had  the  first  patient  survived,  the  throm- 
bosis would  certainly  have  been  followed  by  abscess.  Clinically,  the 
value  of  the  case  is  that  it  may,  in  rare  cases,  help  to  explain 
the  seat  of  an  obscure  abdominal  swelling,  associated  with  fever, 
which  has  followed  a  thrombosis,  and  which  physical  examination 
cannot  localize  in  the  liver." 

Suppuration  always  begins  in  the  interstitial  tissue,  either 
within  the  gland  or  in  the  connective  tissue  around  it.  A  suppurative 
inflammation  and  formation  of  an  abscess  are  different  stages  of  the 
same  process.  Peripancreatitic  suppuration  commences,  in  most 
instances,  in  the  adjacent  lymphatics;  the  pus  surrounding  the 
lymph  glands,  or  forming  a  small  abscess. 

In  the  vicinity  of  the  pancreas  these  peri-lymphatic  abscesses 

1  Pathological  Observations  on  the  Pancreas,  St.  Bartholomew's  Hospital 
Reports,  vol.  xviii.  p.  207. 

2  Pathological  Society's  Transactions,  p.  210. 


ABSCESS    OF   THE   PANCREAS.  3B5 

are  not  nn frequently  met  with  as  one  of  the  pathological  conditions 
of  pyaemia.  Thus,  an  abscess  in  the  pancreas  with  perforation  into 
the  peritoneal  cavity,  was  examined  by  Perle.1  Tulpius  saw  an 
abscess  of  the  pancreas  as  a  secondary  lesion  after  an  attack  of 
malarial  fever.  Schmackpfeffer  observed  the  same  condition  after 
an  operation  for  strangulated  hernia,  and  Portal  after  extirpation  of 
a  testicle.  But  suppuration  in  the  pancreas  sometimes  takes  place 
as  an  independent  affection,  without  the  presence  of  an  appreciable 
infection-atrium,  and  in  these  cases  we  must  assume  that  the  essen- 
tial and  specific  noxse  are  carried  along  with  the  circulating  blood, 
and  that  localization  takes  place  upon  a  soil  prepared  for  their 
reception  and  growth  by  previous  alteration  in  texture  or  circulation. 
In  some  instances  the  process  begins  upon  the  outer  surface  of  the 
gland,  the  pus  separating  the  gland  from  its  attachments.  In  the 
case  described  by  Gendrin  the  pancreas  appeared  to  have  been 
completely  detached,  and  was  lying  loose  in  the  abscess  cavity. 

Many  of  these  parapancreatic  abscesses  do  not  present  well- 
defined  borders:  the  pus  manifests  a  tendency  to  burrow  in  the 
vicinity  of  the  mesocolon  and  the  retroperitoneal  space,  and  is  apt  to 
perforate  into  the  bursa  omentalis,  or  into  some  other  portion  of  the 
peritoneal  cavity,  or,  lastly,  finds  its  way  into  one  of  the  adjacent 
hollow  organs,  as  the  stomach  or  intestinal  tract.  Van  Derveren 
reports  the  case  of  a  female,  fifty-nine  years  of  age,  who  had  suffered 
for  thirty  years  from  attacks  of  gastralgia.  At  the  necropsy,  it  was 
ascertained  that  the  indurated  pancreas  had  perforated  the  posterior 
wall  of  the  stomach.  The  opening  represented  a  round  ulcer,  two 
and  a  half  inches  in  diameter,  with  indurated  margins.  In  this 
aperture  eroded  vessels  could  be  seen.  The  fistulous  tract  com- 
municated with  the  pancreatic  duct.  The  stomach  and  intestines 
contained  blood,  but  no  other  evidences  of  disease  could  be  found. 
In  Percival's  case  the  abscess  ruptured  into  the  bowel,  the  stools 
containing  fetid  pus  and  blood.  A  similar  case  was  observed  by 
Eaggarth.2 

The  suppurative  process,  however,  may  extend  in  an  opposite 
direction,  from  the  stomach  to  the  pancreas.'     A  communication 

1  De  Pancreas  ejusque  morbis,  Dissert.  Berol.,  1837. 
•  Transactions  of  the  College  of  Physicians  in  Ireland,  vol.  ii. 
I.'okitansky,  Lehrbuch  der  pathol.  Anatomic,  Wien,  vol.  iii.  p.  168. 


366  EXPERIMENTAL  SURGERY. 

between  the  stomach  and  the  pancreas  is  sometimes  established  by 
perforation  of  a  gastric  ulcer  in  this  direction.  Around  the  margins 
of  the  ulcer,  between  the  stomach  and  pancreas,  adhesions  are 
formed,  an  occurrence  which  prevents  extravasation  of  the  contents 
of  the  stomach  into  the  peritoneal  cavity.  A  number  of  the  terminal 
openings  of  the  accessory  pancreatic  ducts  have  been  observed  upon 
the  cicatrized  surface  of  a  gastric  ulcer.  In  place  of  the  formation 
of  a  permanent  pancreatico-gastric  fistula  as  described  by  Rokitansky, 
perforation  of  the  stomach  in  closer  proximity  to  the  pancreas  may 
give  rise  to  diffuse  and  rapidly  fatal  parapancreatitis  or  peripan- 
creatitis. 

The  indirect  primary  cause  of  a  pancreatic  abscess  may  be  due 
to  a  calculus  in  the  pancreatic  duct.  Fournier  has  recorded  a  case 
where,  on  post-mortem  examination,  an  enormous  abscess  was  found 
in  the  head  of  the  pancreas,  which  contained  numerous  calculi.  The 
tumor  was  sufficiently  large  to  be  readily  detected  in  the  epigastric 
region  during  life. 

An  abscess  of  the  pancreas  may  also  originate  in  a  preexisting 
cyst  of  the  organ.  Kilgour's  case,  detailed  above,  had  undoubtedly 
such  an  origin.  The  abscess  cavity  was  as  large  as  a  teacup,  and 
contained  a  milky  fluid  and  caseous  particles,  which  were  undoubtedly 
a  mixture  of  pus  and  pancreatic  juice.  The  disease  was  attended  by 
chills  and  fever,  which  indicated  that  the  retention  cyst  had  become 
the  seat  of  an  acute  suppurative  inflammation. 

As  primary,  idiopathic,  uncomplicated,  purulent  inflammation  of 
the  pancreas  is  an  exceedingly  rare  affection,  it  is  of  great  practical 
importance  in  the  surgical  treatment  of  such  cases  to  determine,  if 
possible,  the  predisposing  cause  or  causes,  and  to  remove  them  or 
render  them  inert  at  the  time  of  operation. 

2.     Symptoms  and  Diagnosis. 

The  presence  of  pus  within  the  pancreas  or  in  its  immediate 
vicinity  is  not  indicated  by  any  characteristic  or  positive  symptoms. 
The  symptoms  always  point  to  the  stomach  or  liver  as  the  seat  of 
the  disease.  The  most  prominent  and  constant  symptoms  which 
have  been  observed  are  nausea,  vomiting  of  a  clear  greenish  or  viscid 
fluid,  thirst,  loss  of  appetite,  constipation,  progressive  emaciation, 
and  distention  of  the  epigastrium. 

In  almost  all  cases  the  patients  presented  a  sallow,  cachectic 


ABSCESS   OF  THE   PANCREAS.  36*5 

appearance,  and  were  exceedingly  anaemic.  Ascites  and  cedema  of 
the  lower  extremities  were  present  a  number  of  times.  In  several 
instances  the  inflammatory  process  in  the  pancreas  extended  to  the 
bile-duct,  or  caused  stenosis  of  the  duct  by  compression;  conditions 
which  are  followed  by  biliary  retention,  a  symptom  which  has 
usually  been  interpreted  as  an  evidence  of  primary  disease  of  the 
liver  or  bile -ducts.  The  progressive  anseinia  and  emaciation,  in  the 
absence  of  other  tangible  lesions,  are  symptoms  which  should 
always  direct  attention  to  the  pancreas  as  the  seat  of  the  disease. 

Fever  was  seldom  a  conspicuous,  and  never  a  constant  symptom 
of  suppurative  pancreatitis.  The  use  of  the  thermometer  in  the 
diagnosis  of  suppuration  in  this  locality  is  important,  but  it  fur- 
nishes no  positive  evidence.  If  the  abscess  is  large,  it  will  be 
recognized  by  palpation  and  deep  percussion,  as  a  tumor  in  the 
epigastric  region.  In  such  cases  a  probable  diagnosis  may  be  made 
by  a  careful  and  systematic  physical  examination,  and  by  reasoning 
by  exclusion. 

An  abscess  within  the  gland  is  always  located  in  the  bursa 
omentalis :  a  peripancreatic  abscess  in  the  bursa  omentalis,  duodeno- 
jejunal fossa,  or  upper  portion  of  the  peritoneal  cavity;  and  a 
parapancreatic  abscess  in  the  retroperitoneal  space.  Inflation  of 
the  stomach  will  often  serve  a  useful  purpose  in  the  differential 
diagnosis  of  tumors  in  the  epigastric  region.  In  obscure  cases, 
manual  exploration  of  the  rectum  may  add  important  and  sometimes 
decisive  information. 

Age  is  also  an  important  element  to  be  considered  in  the  diag- 
nosis. Most  of  the  cases  of  abscess  of  the  pancreas  were  patients 
of  more  than  forty  years  of  age,  and  often  persons  of  intemperate 
habits.  Puncture  with  an  aseptic  capillary  needle  will  demonstrate 
the  presence  or  absence  of  pus,  but  will  not  add  material  informa- 
tion in  locating  with  accuracy  the  abscess  cavity. 

Finally,  in  all  cases  in  which  a  tumor  can  be  felt  in  the  epigas- 
tric region,  and  a  probable  diagnosis  can  be  made  regarding  its 
benign  character,  an  exploratory  laparotomy  should  be  resorted  to 
for  the  purpose  of  making  an  accurate  anatomical  diagnosis. 

3.     Prognosis 

The  prognosis  of  abscess  of  the  pancreas  is  always  unfavorable. 
Death  is  produced  by  progressive  emaciation  and  inanition,  by  sgptic 


368  EXPERIMENTAL  SURGERY. 

absorption,  or  secondary  lesions  in  adjacent  organs.  In  acute, 
diffuse  pancreatic  abscess  a  fatal  termination  may  take  place  in  a 
few  days.  One  of  the  great  dangers  of  abscess  in  this  locality  is 
the  close  proximity  of  numerous  important  veins,  which  become 
implicated  by  extension  of  the  suppurative  inflammation  to  their 
walls,  producing  a  suppurative  thrombo-phlebitis,  with  all  its  disas- 
trous consequences.  Perforation  of  the  abscess  into  the  stomach  or 
intestinal  tract  is  the  most  favorable  spontaneous  termination,  and 
has  resulted,  at  least  in  one  instance,  in  a  cure.  Perforation  of  the 
abscess  into  the  peritoneal  cavity  would  hasten  death  by  inducing  a 
rapidly  fatal  septic  peritonitis. 

4.     Treatment. 

The  remarkable  success  which  has  attended  the  treatment  of 
pelvic  and  abdominal  abscesses  by  laparotomy  justifies  the  hope 
that,  in  the  near  future,  the  same  treatment  will  be  extended  to 
abscess  of  the  pancreas.  It  is  true  that  the  difficulties  which 
surround  the  treatment  of  abscesses  in  this  region  are  many,  but 
they  are  not  insurmountable.  Multiple  abscesses,  disseminated 
throughout  the  entire  organ,  and  especially  its  head,  are  not  amen- 
able to  successful  surgical  treatment.  Circumscribed  endopancreatic 
abscess  in  the  peripheral  portion  of  the  body  or  tail  of  the  pancreas 
should  be  treated  by  partial  excision  of  the  pancreas,  in  all  cases 
where  the  isolation  of  that  portion  of  the  organ  can  be  accomplished 
without  inflicting  serious  injury  on  adjacent  important  organs. 

When  extirpation  is  impossible,  as  when  the  abscess  is  located 
in  the  head  of  the  pancreas,  it  must  be  treated  by  incision  and 
drainage.  This  is  accomplished  in  the  same  manner  as  in  the  treat- 
ment of  a  pancreatic  cyst.  In  some  instances,  the  access  to  the 
abscess  is  rendered  difficult  by  distention  of  the  stomach,  the  dilated 
organ  overlapping  the  pancreas.  In  such  cases,  the  stomach  must 
be  pushed  upward,  and  subsequent  distention  guarded  against  by 
ordering  an  absolute  diet  until  the  external  fistula  has  been  estab- 
lished. The  external  incision  must,  in  all  cases,  correspond  to  the 
most  prominent  part  of  the  swelling,  as  it  is  of  the  greatest  impor- 
tance to  incise  the  abscess  at  a  point  where  the  distance  between  the 
surface  of  the  abscess  and  the  abdominal  wall  is  the  shortest.  Incision 
of  the  great  omentum  will  be  required  in  all  instances. 


ABSCESS   OF  THE   PANCREAS.  369 

In  making  an  external  fistula  in  the  treatment  of  the  pancreatic 
abscess,  it  is  essential  to  protect  the  muscular  and  connective  tissues 
of  the  external  incision  against  contact  with  pus,  by  lining  the 
margins  of  the  wound  with  the  parietal  peritoneum  before  the  serous 
covering  of  the  anterior  wall  of  the  abscess  is  stitched  to  the  margins 
of  the  wound.  One  of  the  greatest  difficulties  that  will  be 
encountered  in  this  operation  will  be  the  approximation  of  the  peri- 
toneal surface  of  the  abscess  to  the  margins  of  the  wound,  on  account 
of  the  distance  between  the  siirface  of  the  abscess  and  the  anterior 
abdominal  wall;  this  difficulty  will  decrease  in  proportion  to  the 
prominence  of  the  swelling. 

The  size  of  the  external  incision  will  exert  an  important  influ- 
ence in  this  direction.  If  the  incision  is  large,  the  margins  of  the 
wound  can  be  turned  inward,  thus  facilitating  the  suturing  of  the 
anterior  wall  of  the  abscess  to  the  margins  of  the  wound.  As  a 
rule,  it  may  be  relied  upon  that  the  anterior  wall  of  the  abscess, 
covered  by  peritoneum,  is  quite  thick,  so  that  there  is  little  danger 
of  penetrating  the  abscess  cavity  with  the  needle  in  suturing. 
Previous  evacuation  of  the  abscess  cavity  by  aspiration  would 
diminish  the  danger  of  extravasation  of  pus  through  the  needle 
punctures,  but  would  also  render  approximation  difficult  by  the 
recession  of  the  abscess  wall,  and  should,  therefore,  not  be  resorted 
to  unless  the  swelling  is  sufficiently  prominent  to  render  this  circum- 
stance of  little  importance. 

As  the  suturing  of  the  two  peritoneal  surfaces  is  done  for  the 
purpose  of  preventing,  in  the  first  place,  extravasation  of  pus  into 
the  peritoneal  cavity;  and,  secondly,  of  securing  permanent  adhesions 
between  the  abscess  wall  and  the  margins  of  the  wound,  it  is  impor- 
tant to  apply  the  sutures  closely  together  and  to  grasp  the  tissues 
in  such  a  maimer  that  tearing  through  of  the  sutures  is  impossible. 
As  considerable  tension  may  follow,  it  would  be  advisable,  in  this 
particular  instance,  to  use  silk  sutures.  As  in  these  cases  time  is  an 
important  element,  incision  and  drainage  should  immediately  follow 
the  suturing. 

The  remaining  steps  of  the  operation  will  depend  upon  circum- 
stances. If  the  abscess  is  endopancreatic  or  peripancreatic,  simple 
incision,  drainage,  and  disinfection  will  answer  all  indications.  If, 
however,  the  purulent  cavity  is  located  behind  the  peritoneum  and 
occupies  the  connective  tissue  space  behind  the  pancreas,  it  would 


370  EXPERIMENTAL  SURGERY. 

appear  rational  to  drain  the  abscess  posteriorly  through  one  of  the 
lumbar  regions  above  the  kidney,  by  pushing  a  long  closed  forceps 
in  a  proper  direction  through  the  posterior  and  lateral  wall  of  the 
abscess  until  its  point  can  be  felt  under  the  skin  externally.  A 
small  cut  in  the  skin  over  its  point  will  enable  the  operator  to  push 
the  instrument  through,  and,  by  dilating  its  blades,  to  widen  the 
canal  sufficiently  to  permit  the  insertion  of  a  large  drainage  tube. 
In  this  manner  the  most  desirable  method  of  drainage — through 
drainage — could  be  established,  which  would  render  subsequent 
disinfection  and  evacuation  of  the  abscess  a  comparatively  easy  task. 
In  cases  where  an  anterior  pancreatic  fistula  cannot  be  established 
on  account  of  the  distance  between  the  abscess  and  the  anterior 
abdominal  wall,  we  might  resort  to  lumbar  drainage  and  closure  of 
the  incision  in  the  anterior  wall  of  the  abscess  by  carefully  inverting 
and  approximating  the  peritoneum  over  the  wound  with  fine  silk 
sutures. 

That  the  utmost  care  in  the  application  of  antiseptic  precautions 
should  be  resorted  to  in  the  evacuation  of  pus  in  this  remote  region, 
by  any  of  these  procedures,  requires  no  argument.  I  will  repeat 
that  a  positive  diagnosis  of  the  presence  and  precise  location  of  a 
pancreatic  abscess  is  only  possible  by  resorting  to  exploratory 
laparotomy,  and  that  this  diagnostic  aid  should  be  always  resorted 
to  when  the  history  of  the  case  and  the  symptoms  and  signs  pre- 
sented are  sufficiently  suggestive  to  point  to  a  probable  diagnosis. 

The  abscess  found  and  located  by  abdominal  section  should  be 
removed  by  partial  extirpation  of  the  pancreas  when  it  is  endopan- 
creatic  and  located  near  the  splenic  end  of  the  pancreas.  When 
extirpation  is  impossible,  or  when  it  is  located  in  the  head  or  on  the 
anterior  surface  of  the  pancreas,  it  should  be  treated  by  the  forma- 
tion of  an  anterior  abdominal  fistula;  when  located  behind  the  pan- 
creas, by  through  drainage,  or  lumbar  drainage  performed  through 
the  abdominal  cavity. 

X.    Hemorrhage  of  the  Pancreas. 

A  number  of  post-mortem  examinations  have  shown  that  certain 
cases  of  sudden  death  were  caused  by  haemorrhage  of  the  pancreas, 
inasmuch  as  no  other  evidences  were  found  which  could  explain  the 
cause  of  death.  In  some  as  yet  unaccountable  way,  even  a  moderate 
haemorrhage  in   this   locality  has   been   sufficient   to   destroy  life. 


HEMORRHAGE   OF   THE   PANCREAS.  .  371 

Zenker  has  affirmed  that  in  these  cases,  pressure  upon  the  solar 
plexus  and  semilunar  ganglion  produces  paralysis  of  the  heart,  to 
which  he  attributes  the  immediate  cause  of  death.  If  we  recollect 
that  tumors  of  the  pancreas,  even  when  of  considerable  size,  do  not 
destroy  life  in  this  manner,  it  seems  that  the  true  explanation  of  the 
great  danger  which  attends  haemorrhage  of  the  pancreas  remains  to 
be  ascertained.  Practically  it  is  important  to  differentiate  between 
diffuse  haemorrhage  into  the  substance  of  the  organ  and  its  adjacent 
tissue,  and  circumscribed  accumulations  of  blood  or  haemorrhage 
cysts  of  the  pancreas,  as  the  latter  condition  presents  more  favorable 
indications  for  surgical  treatment. 

i.    Varieties, 
a.     Heemorrhagic  Cysts. 

Case  1.  Anger '  reports  a  case  of  hemorrhagic  cyst  of  the  pancreas  in  a 
man.  aged  seventy-two  years,  who  had  been  a  soldier  for  ten  years,  during 
which  time  he  had  received  several  wounds.  Later  he  suffered  fracture  of  sev- 
eral ribs  on  the  left  side  from  a  severe  contusion,  from  which  injury,  however,  he 
recovered  completely  after  three  months'  treatment  in  the  hospital.  No  history 
of  syphilis.  Five  months  ago  lower  limbs  became  cedematous,  and  for  the  last 
six  weeks  ascites  was  present.  He  was  admitted  into  the  Beaujon  Hospital 
February  27,  1865.  At  this  time  the  following  conditions  were  noted:  (Edema 
of  lower  extremities;  ascites;  breathing  difficult  and  stertorous;  bronchitis  on 
left  side  of  chest,  and  hydrothorax  on  opposite .  side.  Diaphragm  pushed 
upward.  Pulse  100,  irregular  and  intermittent.  Diarrhoea  and  loss  of  appe- 
tite. No  delirium.  Urine  contained  no  albumen.  A  stimulating  treatment 
was  adopted.  March  1st.  the  patient  died,  the  pulse  having  been  for  a  time 
exceedingly  feeble  and  intermittent.  The  breathing  toward  the  last  was  very 
labored  and  the  patient  was  unable  to  lie  down. 

Autopsy.  Pleuritic  effusion  on  left  side,  bronchitis.  Liver  small,  some- 
what contracted,  but  not  cirrhotic.  Serous  effusion  in  pericardium;  heart 
dilated,  mitral  valve  insufficient.  On  opening  the  abdomen  a  tumor,  the  size 
of  a  foetal  head,  was  found  in  front  of  and  on  a  level  with  the  left  kidney. 
This  tumor  was  bounded  in  front  by  the  stomach  and  the  transverse  colon, 
above  by  the  diaphragm,  below  by  the  descending  colon,  behind  by  the  kidney, 
toward  the  median  line  by  the  pancreas,  and  on  the  outside  and  above  by  the 
spleen.  It  was  loosely  connected  with  the  kidney  and  spleen  by  connective 
tissue,  in  which  the  vessels  of  these  organs  could  be  readily  seen.  The  tumor 
was  evidently  connected  with  the  pancreas.  The  external  surface  was  irregular 
and   nodulated,  the  anterior  wall  of  variable  thickness.      Fluctuation   plain. 

1  Bulletin  de  la  soci6t6  anatomique  de  Paris,  xl.,  Ann6e  1865,  2me  s6rie, 
tome  x.  p.  \\)'i. 


372  EXPERIMENTAL   SURGERY. 

The  vessels  of  the  spleen  were  intimately  connected  with  the  posterior  surface 
and  were  not  easily  isolated. 

On  careful  dissection  the  lobules  of  the  pancreas  could  be  separated  from 
the  tumor,  but  the  walls  of  the  cyst  contained  a  tissue  which  resembled 
glandular  structure.  On  opening  the  cyst  a  considerable  quantity  of  dark  fluid 
blood  escaped,  which  contained  a  number  of  small,  recent  coagula.  The  inner 
surface  of  the  cyst  was  uneven  and  reticulated,  resembling  in  appearance  the 
interior  of  the  right  ventricle.  On  the  surface  of  the  prominences,  diverticula 
could  be  seen,  which  were  in  free  communication  with  the  principal  cyst. 
The  wall  of  the  cyst  was  very  much  indurated  and  thickened  at  four  or  five 
places.  Some  of  these  nodules  were  fibro-cartilaginous  in  structure,  while 
others  had  undergone  calcification. 

Sections  of  the  cyst  wall  showed  under  the  microscope  nucleated  epithelial 
cells,  which  resembled  in  structure  the  epithelial  cells  in  the  pancreas.  Acinous 
groups  of  glandular  tissue  were  also  found.  The  reticulated  structure  in  the 
interior  of  the  cyst  contained  vessels  and  remnants  of  the  acini.  The  author 
came  to  the  final  conclusion  that  the  tumor  was  a  cyst,  located  in  the  tail  of 
the  pancreas.  The  presence  of  blood  in  the  cyst  was  explained  by  the  suppo- 
sition that,  during  the  progressive  dilatation  of  the  cyst,  some  of  the  vessels 
in  the  connective  tissue  reticulum  had  ruptured. 

M.  Le  Dentu,  who  examined  the  cyst,  also  came  to  the  conclusion  that  the 
bleeding  had  taken  place  into  a  preexisting  cyst.  What  symptoms  the  pres- 
ence of  the  tumor  had  produced  during  life  could  not  be  ascertained,  as  the 
patient  was  being  treated  for  organic  disease  of  the  heart,  and  the  tumor  was 
not  recognized  during  life. 

Case  2.  Storck 1  observed  the  following  case.  The  patient  was  attacked 
during  the  menstrual  period  by  vomiting,  which  was  followed  by  coldness  of 
the  extremities,  palpitation  of  the  heart,  and  dyspnoea.  Soon  after  this  time 
a  pulsating  tumor  was  detected  in  the  epigastric  region,  which  caused  consid- 
erable pain.  The  patient  also  suffered  from  constipation  and  attacks  of 
vomiting.  She  died  three  and  one-half  months  after  the  first  attack.  At  the 
autopsy  the  entire  pancreas  was  found  enormously  dilated,  weighing  with  its 
contents  thirteen  and  one-half  pounds.  On  cutting  into  it,  it  was  found  filled 
with  coagulated  blood.  Judging  from  the  condition  of  the  coagula,  bleeding 
had  occurred  at  intervals.  The  weight  of  the  tumor  had  caused  injurious 
pressure  upon  adjacent  organs.  Le  Dentu  believed  that  the  haemorrhage  was 
caused  by  the  act  of  vomiting,  and  had  taken  place  into  a  preexisting  cyst  of 
the  pancreas. 

Case  3.  John  Parsons 2  reports  a  case  where  haemorrhage  into  a  preexist- 
ing cyst  proved  fatal  after  the  latter  had  ruptured  into  the  intestinal  tract. 
The  patient  was  a  female,  sixty  years  of  age,  who  had  suffered  from  vague 
dyspeptic  symptoms  for  an  indefinite  length  of  time.  When  she  was  examined 
by  the  reporter,  a  fluctuating  tumor  the  size  of  an  orange  could  be  felt  in  the 

1  Archiv  gen.  de  Paris,  Mai  et  Juillet,  1836. 
3  British  Medical  Journal,  1857. 


HEMORRHAGE    OF  THE   PANCREAS.  373 

epigastrium,  just  below  the  greater  curvature  of  the  stomach.  Emaciation 
progressed  rapidly.  The  tumor  disappeared  suddenly,  at  the  same  time  a 
viscid,  dirty  white  fluid  was  discharged  through  the  bowels.  The  tumor  reap- 
peared in  a  short  time,  and  ruptured  a  second  time  into  the  intestines,  followed 
by  haemorrhage  into  the  ruptured  cyst,  which  proved  fatal.  At  the  autopsy, 
the  pancreas  was  found  excavated  into  a  wide  canal,  which,  at  either  extremity, 
was  dilated  into  a  cyst.  The  walls  of  the  cysts. were  of  the  firmness  of  carti- 
lage, and  the  organ  was  adherent  to  the  stomach,  kidney,  and  colon.  Coagu- 
lated blood  was  found  in  the  dilated  duct  and  cysts. 

Remarks. — In  Anger's  case  there  is  room  for  speculation  con- 
cerning the  origin  of  the  cyst  and  the  source  of  haemorrhage.  As 
the  cyst  had  not  ruptured  and  did  not  remain  in  communication 
with  the  patent  pancreatic  duct  on  the  proximal  side,  we  can  only 
explain  the  absence  of  altered  pancreatic  juice,  or  at  least  the  absence 
of  cyst  contents  previous  to  the  occurrence  of  the  haemorrhage,  by 
assuming  that  absorption  took  place  as  the  haemorrhage  increased,  if 
we  adopt  the  idea  that  the  bleeding  occurred  into  a  cyst  which  had 
formed  before  the  haemorrhage  took  place. 

Two  other  explanations  might  be  offered.  First,  that  the 
parenchymatous  haemorrhage  produced  the  cyst;  the  circumscribed 
coagulum  separating  the  interstitial  tissue,  and  the  lining  of  this 
space  with  endothelial  cells  developed  from  the  connective  tissue 
cells,  and  subsequent  haemorrhage  from  the  interior  of  the  cyst  wall. 
Again,  the  haemorrhagic  cyst  might  have  originated  in  a  dilatation 
of  one  of  the  vessels  of  the  pancreas,  a  varicose  ectasia  of  a  vessel. 

In  the  second  case  it  appears  more  than  probable  that  haemor- 
rhage occurred  by  rupture  of  a  vessel  and  extravasation  of  blood  into 
the  altered  parenchyma  of  the  gland,  distending  the  entire  capsule 
of  the  organ — in  other  words,  a  haematoma  of  the  pancreas.  In 
Parson's  case  the  clinical  history  and  the  post-mortem  appearances 
prove  beyond  all  doubt  that  the  fatal  haemorrhage  took  place  into  a 
preexisting  pancreatic  cyst.  The  immediate  cause  of  haemorrhage 
in  this  case  was  undoubtedly  due  to  inflammatory  changes  in  the 
interior  of  the  cyst  after  the  first  rupture,  and  to  sudden  diminution 
of  intracystic  pressure  by  the  second  rupture 

b.    Diffuse   Haemorrhage. 

Case  1.  Reported  by  H.  Hudson  Rngg.1  A  man,  aged  forty-two  years, 
had  just  recovered  from  an  attack  <>f  acute  articular  rheumatism,  when  he  was 

1  'I  he  Lancet,  May,  I860. 


374  EXPERIMENTAL  SURGERY. 

attacked  suddenly  with  a  severe  pain  in  the  left  lumbar  region.  He  became 
collapsed  almost  instantly.'  This  was  followed  by  cold,  clammy  sweat  and 
other  symptoms  of  acute  anaemia.  He  never  rallied,  and  died  within  a  few 
hours.  On  opening  the  abdomen  after  death  a  large  quantity  of  recently 
extravasated  blood  was  found  between  the  pancreas  and  left  kidney.  A  careful 
search  for  the  source  of  haemorrhage  was  made,  when  it  was  found  that  the 
blood  had  escaped  through  an  opening  of  considerable  size,  which  presented 
the  appearance  of  an  ulcer,  on  the  anterior  surface  of  the  pancreas,  which 
contained  a  blood-clot  the  size  of  a  walnut.  Sections  through  the  pancreas 
showed  a  number  of  small  excavations  filled  with  blood,  the  size  of  a  hazelnut 
and  smaller,  which  looked  like  aneurismal  dilatations. 

Case  2.  Reported  by  Oppolzer.1  The  patient  suffered  from  severe  pain 
in  the  epigastric  region,  followed  by  vomiting,  which  always  aggravated  the 
suffering.  The  vomited  matter  consisted  of  mucus  and  bile.  The  disease  was 
attended  by  fever,  very  frequent  pulse,  cold  extremities.  The  bowels  were 
constipated.  No  blood  was  vomited,  and  the  case  was  diagnosticated  as  per- 
forating ulcer  of  the  posterior  wall  of  the  stomach.  On  the  third  day  after 
admission  to  the  hospital  he  died.  At  the  autopsy  the  stomach  was  found  in 
a  healthy  condition,  but  around  the  pancreas  and  between  the  layers  of  the 
mesentery  a  copious  effusion  of  blood  was  found.  The  pancreas  was  the  source 
of  haemorrhage.  This  organ  was  enlarged  to  double  its  normal  size,  of  dark 
red  color,  and  on  section,  was,found  infiltrated  with  a  blood-stained  exudation 
between  the  acini. 

Case  3.  Reported  by  Hilty.2  The  patient  was  a  mechanic,  aged  thirty; 
tall,  stout,  and  muscular,  but  of  intemperate  habits.  One  evening  he  drank 
beer  to  excess,  and  on  the  following  morning  without  any  premonitory  symp- 
toms, he  was  seized  suddenly  with  a  painful  tension  of  the  abdomen,  which 
gradually  increased  in  intensity.  He  was  sent  to  the  hospital,  where  on  exami- 
nation, he  was  found  in  a  collapsed  condition.  Extremities  cold,  forehead 
covered  with  a  cold,  clammy  perspiration.  All  the  symptoms  indicated  acute 
anaemia.  On  physical  examination  nothing  abnormal  was  found,  except  that 
the  upper  part  of  the  abdomen  was  distended  and  painful,  especially  to 
pressure.  Diagnosis  of  poisoning  or  gastritis  was  made,  and  treatment 
adopted  in  accordance  with  this  view.  The  patient  never  rallied,  and  died  in 
the  evening  of  the  following  day. 

At  the  necropsy  the  omentum  and  mesentery  were  found  loaded  with  fat. 
No  abdominal  effusion  and  no  trace  of  peritonitis.  The  diaphragm  was  pushed 
upward  as  high  as  the  fourth  rib.  In  the  connective  tissue  around  the  pancreas 
a  copious  effusion  of  blood  was  found.  The  pancreas  was  double  its  normal 
size,  firm  in  structure,  and  of  a  dark  violet  color.  On  section  the  lobules  were 
seen  to  be  of  a  dark  color,  and  the  interlobular  tissue  infiltrated  with  blood; 
this  infiltration  was  most  copious  in  the  head  of  the  organ.  The  gland  duct 
was  normal,  but  the  vein  running  along  the  lower  border  of  the  pancreas  was 

1  Medizinische  Neuigkeiten,  April,  1859. 

2  Correspondenzblatt  fur  Schweizer  Aerzte,  Nov.  15,  1877. 


HAEMORRHAGE   OF  THE   PANCREAS.  375 

distended   with   blood-clots.     No   other    pathological   conditions  were  found 
which  could  explain  the  sudden  death. 

Case  4.  Described  by  Portal.1  This  is  the  first  case  of  this  kind  on 
record.  A  merchant  had  suffered  for  two  years  from  colicky  pain  in  the 
abdomen,  nausea,  and  diarrhoea;  emaciation  appeared  early  and  continued 
progressively.  Twenty  days  before  his  death  fever  made  its  appearance.  The 
pancreas  presented  a  violet  color,  was  softened,  and  from  its  entire  surface 
exuded  a  black  offensive  fluid.  Stomach  and  duodenum  showed  evidences  of 
inflammation  at  some  points  adjacent  to  the  pancreas. 

Case  5.  Reported  by  Haller  and  Klob.2  Patient  was  a  man,  sixty-six 
years  of  age,  who  had  died  after  a  short  illness.  The  pancreas  was  found 
almost  completely  detached,  its  only  connection  with  the  adjacent  organs  being 
a  few  strings  of  connective  tissue.  It  was  surrounded  by  a  serous  fluid.  The 
stomach  was  perforated  from  without,  the  cells  of  the  pancreas  were  disinte- 
grated, granular,  and  changed  into  detritus,  and  the  splenic  vein  was  filled 
with  a  thrombus. 

Case  6.  Reported  by  Kollman. 3  Female,  suffering  from  stenosis  of 
mitral  valve  and  pleuritis  on  the  left  side.  One  afternoon,  after  having  par- 
taken of  a  liberal  dinner,  she  had  an  attack  of  diarrhoea,  but  no  vomiting. 
During  the  night  she  had  a  chill,  and  an  anxious  sensation  with  jactitations. 
In  the  morning  of  the  following  day  she  felt  greatly  improved,  but  soon  after 
expired  suddenly.  At  the  autopsy  there  was  found  subperitoneal  extravasa- 
tion of  blood  at  the  pyloric  end  of  the  stomach.  Mucous  membrane  of  duo- 
denum along  the  convex  side  was  infiltrated  with  blood,  but  intact.  Pancreas 
hypersemic,  and  surrounded  with  an  extravasation  of  blood,  which  was  most 
marked  in  the  retroperitoneal  connective  tissue,  extending  to  the  hilus  of  the 
spleen.  The  tail  of  the  pancreas  was  more  hyperasmic  than  the  remaining 
portion  of  the  gland,  and  was  infiltrated  with  blood. 

Case  7.  Gerhard's  case,  reported  by  Kollman.4  The  patient  was  a 
female,  who,  from  the  symptoms  presented,  was  supposed  to  suffer  from 
bronchial  catarrh,  emphysema,  ascites,  and  anasarca.  She  was  suddenly 
seized  with  collapse,  and  died  in  a  few  hours.  At  the  necropsy  the  subperi- 
toneal tissue  of  the  duodenal  peritoneum  was  found  suffused  with  blood.  Con- 
siderable haemorrhage  into  pancreas,  and  the  retroperitoneal  space  behind 
pancreas  was  distended  with  blood. 

Remarks. — A  careful  perusal  of  the  above  cases  must  satisfy  the 
most  casual  observer  that  the  haemorrhage  was  produced  by  different 
causes,  and  constituted  simply  an  expression  of  different  pathological 
conditions.    In  the  material  presented,  three  distinct,  primary,  patho- 

1  Trait6  de  I'  apoplexie,  Paris,  1811. 

2  Wiener  Zeitschrift,  N.  F.,  11,  37,  1859. 

3  Bayr.  ftrzt.  Intelligenzbl.,  No.  39,  1881. 

4  Op.cit. 


376  EXPERIMENTAL  SURGERY. 

logical  conditions  will  be  recognized:  1.  Disease  of  the  blood-vessels 
of  the  pancreas;  2.  Chronic  parenchymatous  degeneration  of  the 
gland:  3.   Acute  hemorrhagic  pancreatitis. 

In  Rugg's  case  the  patient  had  just  passed  through  the  stages 
of  acute  articular  rheumatism,  and  had  not  suffered  from  symptoms 
referable  to  organic  disease  of  the  pancreas,  when  he  died  suddenly 
from  internal  hemorrhage,  which  was  traced  to  the  pancreas.  The 
pancreas  itself  showed  no  other  pathological  changes,  except  circum- 
scribed cavities  filled  with  blood,  which  are  referred  to  as  resembling 
aneurismal  sacs. 

Case  3,  reported  by  Hilty,  is  an  illustration  of  the  second  class. 
Extensive  fatty  degeneration  was  found  to  exist  in  the  tissues  gener- 
ally. Klob  found  interstitial  hemorrhage  in  the  pancreas,  in  con- 
nection with  chronic  interstitial  inflammation  of  the  pancreas,  and  as 
a  result  of  prolonged  congestion  of  the  portal  vein. 

Zenker  reported  three  cases,  which  he  observed  in  the  course  of 
one  year,  to  the  Naturforscher  Verein  at  the  Breslau  meeting  in 
1875.  In  all,  the  amount  of  blood  extravasated  was  slight.  His 
observations  on  hemorrhagic  infiltration  of  the  pancreas  as  a  cause 
of  sudden  death,  are  of  great  importance  to  the  medical  and  legal 
professions.  Death  from  this  cause  takes  place  more  frequently  than 
is  generally  supposed. 

The  facts  observed  by  Zenker  were  nearly  the  same  in  all  cases. 
A  corpulent  subject  died  suddenly,  or  was  found  dead.  Post-mortem 
examination  revealed,  as  the  only  tangible  pathological  change, 
hemorrhagic  infiltration  of  the  pancreas  and  neighboring  connective 
tissue,  and  advanced  fatty  degeneration  of  the  pancreas. 

Further,  there  was  found  in  two  cases,  bloody  effusiou  in  the 
duodenum,  and  in  two,  excessive  engorgement  of  the  semilunar 
ganglion.  Zenker  believes  that  paralysis  of  the  heart,  whether 
directly  or  indirectly  caused,  must  be  regarded  as  the  immediate 
cause  of  death  in  these  cases.  Diffuse  infiltration  is  more  common 
than  circumscribed,  showing  that  the  same  cause  exists  throughout 
the  entire  gland.  The  bloody  effusion  is  usually  not  limited  to  the 
capsule  of  the  gland,  but  infiltrates  the  adjacent  spaces,  more 
especially  the  retroperitoneal  connective  tissue.  The  gland  is 
softened,  the  anterior  serous  covering  disorganized,  and  the  extrava- 
sated blood  escapes  into  the  bursa  omentalis.     These  conditions  are 


HEMORRHAGE    OF  THE  PANCREAS.  377 

followed  rapidly  by  death,  so  that  even  the  peritoneum  shows  no 
secondary  changes. 

In  the  last  class  of  cases,  where  the  haemorrhage  occurs  as  a 
symptom  of  a  peculiar  and  exceedingly  malignant  form  of  inflamma- 
tion of  the  pancreas,  we  have  reason  to  believe  that  the  inflammation 
is  due  to  the  presence  of  a  specific  form  of  infection.  Klebs  believes 
that  in  these  cases  the  corroding  qualities  of  the  pancreatic  secretion 
may  induce  the  destructive  process.  Reasoning  from  analogy,  it  is, 
however,  probable  that  the  immediate  and  essential  cause  is  to  be 
found  in  some  form  of  microbic  infection. 

The  last  two  cases  illustrate  that  prolonged  congestion  of  the 
abdominal  organs,  from  obstruction  to  the  return  of  venous  blood, 
may  act  as  an  exciting  cause  in  producing  parenchymatous  haemor- 
rhage into  the  pancreas  altered  by  antecedent  pathological  con- 
ditions. 

2.     Symptoms  and  Diagnosis. 

The  premonitory  symptoms  which  precede  the  haemorrhage  are 
referable  to  the  particular  kind  of  tissue  changes  in  the  pancreas 
which  predispose  to  rupture  of  the  blood-vessels.  In  all  instances  of 
pathological  haemorrhage  we  have  the  usual  train  of  symptoms  which 
point  to  the  textural  changes  in  the  pancreas  as  the  seat  of  the 
lesion.  Loss  of  appetite,  nausea,  vomiting,  epigastric  pain,  constipa- 
tion, and  debility  are  the  most  prominent  symptoms  in  cases  of 
degeneration  of  the  pancreas.  When  the  haemorrhage  takes  place 
in  the  course  of  an  infective,  hemorrhagic  pancreatitis,  we  have  a 
complexus  of  symptoms  indicating  the  presence  of  an  acute  inflam- 
mation of  the  organ,  usually  attended  by  a  rise  in  temperature.  In 
some  cases  the  haemorrhage  produces  death  so  rapidly,  and  the 
symptoms  which  attend  this  occurrence  are  of  such  short  duration, 
that  it  has  been  impossible  to  determine  them  by  actual  observation. 

When  the  patient  dies  from  loss  of  blood,  the  accident  is 
announced  by  the  well-marked  symptoms  indicative  of  external 
haemorrhage:  a  sharp  pain  in  the  region  of  the  pancreas,  followed 
almost  immediately  by  collapse,  cold  extremities,  absence  of  pulse, 
cold,  clammy  perspiration,  and  a  speedy  death.  If  haemorrhage 
takes  place  into  a  preexisting  cyst,  the  presence  of  which  has  been  pre 
viously  determined,  the  accident  may  be  suspected  if  pain  is  suddenlj 
increased,  the  tumor  becomes  larger  and  more  tense,  and  more  par- 


378  EXPERIMENTAL  SURGERY. 

ticularly  if  the  patient's  condition  indicates  a  sudden  increase  of 
anemia.  Physical  examination  can  be  of  value  only  if  haemorrhage 
occurs  into  a  preexisting  cyst  of  considerable  size,  or  if  the  effusion 
of  blood  is  sufficiently  copious  to  give  rise  to  an  appreciable  swelling 
in  the  immediate  vicinity  of  the  pancreas. 

3.     Treatment. 

The  propriety  of  surgical  treatment  of  pathological  hemorrhage 
of  the  pancreas  can  only  be  entertained  when  the  accident  takes  place 
in  consequence  of  circumscribed,  benign,  pathological  conditions, 
which  in  themselves  do  not  jeopardize  the  life  of  the  patient,  and 
which  admit  of  measures  for  arresting  the  haemorrhage  by  direct 
treatment.  Operative  interference  should,  therefore,  be  limited  to 
the  class  of  cases  described  under  the  head  of  hemorrhagic  cysts  of 
the  pancreas.  In  well-defined  cases  belonging  to  this  group,  it 
would  be  justifiable  to  resort  to  abdominal  section  as  the  only  means 
of  arresting  fatal  hemorrhage,  by  direct  ligation  of  the  bleeding 
points,  or  by  removing  the  localized  portions  of  diseased  tissue  from 
which  the  hemorrhage  has  taken  place. 

For  instance,  in  case  1,  partial  excision  of  the  pancreas  in  which 
the  ectatic  vessel  had  ruptured  would  have  definitely  arrested  the 
hemorrhage  without  interfering  with  the  physiological  function  of 
the  remaining  portion  of  the  gland.  When  profuse  hemorrhage 
takes  place  into  a  preexisting  cyst  of  the  pancreas,  further  hemor- 
rhage can  be  effectually  arrested  by  establishing  an  external  pan- 
creatic fistula  of  large  size,  plugging  the  interior  of  the  cyst  with 
iodoform  cotton,  and  applying  firm  elastic  compression  of  the 
abdomen  with  a  rubber  webbing  bandage  over  the  antiseptic  dress- 
ing. If  this  procedure  should  fail  to  arrest  the  hemorrhage,  the 
abdominal  incision  should  be  enlarged,  and  an  attempt  made  to 
extirpate  the  cyst,  with  or  without  resection  of  that  portion  of  the 
pancreas  from  which  the  cyst  has  grown,  according  to  the  size  or 
location  of  the  cyst. 

In  diffuse  hemorrhage  of  the  pancreas  due  to  localized  lesion, 
the  same  treatment  is  applicable  as  advised  in  the  treatment  of 
hemorrhagic  cysts  of  the  pancreas. 


CYSTS   OF  THE  PANCREAS.  379 

XI.    Cysts  of  the  Pancreas. 

For  a  general  consideration  of  this  part  of  the  subject  I  refer 
to  my  paper  on  "The  Surgical  Treatment  of  Cysts  of  the  Pancreas." ' 
I  refer  to  this  subject  again  for  the  purpose  of  adding  new  cases,  and 
to  modify  the  statement  then  made  concerning  the  etiology  of 
these  cysts.  Since  then  the  following  additional  cases  have  been 
reported : 

Case  1.  Dixon2  reports  an  interesting  case  of  cyst  of  the  pancreas,  which 
terminated  in  death  from  compression  of  the  bile-duct  by  the  cyst.  The 
patient  was  a  male,  forty-two  years  of  age,  who  during  a  period  of  three 
months  had  suffered  from  three  attacks  of  what  seemed  to  be  cholelithiasis, 
before  he  came  under  the  reporter's  care.  For  the  last  ten  days  he  became 
jaundiced.  On  examination  a  tumor  was  found  in  the  region  of  the  gall- 
bladder, about  four  inches  in  diameter,  which  fluctuated  on  palpation,  and 
ascended  and  descended  synchronously  with  the  respiratory  movements,  and 
received  the  impulse  from  the  underlying  aorta.  The  tumor  was  punctured 
and  four  ounces  of  a  yellowish-red  fluid  removed,  which  solidified  on  exposure 
to  the  air.  Two  days  after  the  puncture  the  tumor  was  considerably  larger 
than  before.  The  patient's  strength  gradually  failed,  until  he  died,  thirty-four 
days  after  the  puncture.  At  the  necropsy  it  was  ascertained  that  the  tumor 
was  a  cyst  of  the  pancreas,  with  thick  walls,  and  light  yellow  mucous  contents. 
The  cyst  occupied  the  head  and  part  of  the  body  of  the  pancreas  and  commu- 
nicated with  the  ductus  pancreaticus.  The  tail  of  the  pancreas  also  contained 
a  small  cyst.  The  large  cyst  compressed  the  ductus  choledochus  in  such  a 
manner  as  to  render  it  entirely  impermeable.  It  is  evident  that  in  this  case  a 
removal  of  the  pressure  by  operative  treatment  might  have  restored  the  health 
of  the  patient,  by  removing  the  cause  of  obstruction  to  the  natural  outlet  for 
the  bile. 

Case  2.  Reported  by  Riedel.3  A  woman,  forty-five  years  of  age,  had 
noticed  for  nine  years  a  small  tumor  in  the  upper  portion  of  the  abdomen, 
which  increased  slowly  in  size  until  a  year  and  a  half  before  she  was  examined 
by  Riedel.  After  this  time  growth  was  very  rapid,  so  that  a  great  deal  of  pain 
and  distress  was  experienced  from  the  size  of  the  tumor.  When  she  was 
examined,  the  abdomen  was  filled  completely  with  a  fluctuating  tumor;  the 
pelvis  and  the  lateral  regions  of  the  abdomen  were  free.  Laparotomy  was 
performed  August  27,  1884.  The  slightly  adherent  omentum  was  easily  sepa- 
rated, the  cyst  was  tapped,  and  about  ten  litres  of  a  brownish  fluid  escaped. 
After  evacuation  of  the  cyst,  the  transverse  colon  could  be  seen  immediately 
behind  the  symphysis  pubis.  The  mesocolon  had  been  separated  with  the 
omentum.     The  cyst  was  separated  from   the  loose  attachments  with  neigh- 

1  American  Journal  of  the  Medical  Sciences,  July,  1886. 

2  Medical  Record,  March  If.,  1K84. 

1  Archiv  fUr  klinische  Chirurgie,  vol.  xxxii.  p.  '.CM. 


380  EXPERIMENTAL   SURGERY. 

boring  organs.  Troublesome  haemorrhage  only  occurred  from  the  depth  of 
the  wound  near  the  vertebral  column,  where  a  ligature  en  masse  was  applied 
and  several  vessels  tied;  the  cavity  of  the  wound,  the  size  of  two  fists,  was 
dusted  with  iodoform.  Death  from  peritonitis  after  ninety-six  hours.  At  the 
necropsy  a  portion  of  healthy  pancreatic  tissue  was  found  ligatured  with 
catgut.  The  interior  surface  of  the  cyst  showed,  for  the  most  part,  a  smooth 
surface  without  epithelium.  At  different  points  it  presented  prominences 
which  contained  glandular  tissue. 

Case  3.  Reported  by  Salzer  from  Billroth's  clinic.1  Female,  thirty-three 
years  of  age,  not  married;  suffered  from  an  attack  of  typhus  fever  when  she 
was  eighteen  years  old.  On  admission  into  the  hospital  she  stated  that  during 
her  convalescence  she  noticed  a  swelling  the  size  of  a  goose  egg  in  the  middle 
of  the  abdomen  above  the  umbilicus,  which  disappeared  in  a  few  weeks.  Four 
years  later  the  swelling  reappeared  in  the  same  place;  it  was  now  the  size  of 
a  fist,  but  little  movable,  and  rendered  the  umbilical  region  prominent.  The 
size  of  the  tumor  increased  gradually,  until  four  years  ago  it  had  attained  the 
size  of  a  foetal  head,  and  had  descended  below  the  umbilicus.  A  sensation  of 
weight  in  the  stomach,  vomiting,  pain  in  the  abdomen,  were  the  most  promi- 
nent symptoms  during  the  last  fourteen  days.     Menstruation  regular. 

Before  the  operation  a  systematic  and  careful  examination  showed  no 
disease  in  any  other  organ.  Circumference  of  abdomen  below  the  umbilicus, 
ninety  centimeters.  An  unusually  large  vessel  was  detected  in  the  abdominal 
wall  in  the  left  hypochondrium,  which  pulsated  strongly,  and  over  which,  by 
auscultation,  a  bruit  could  be  heard.  Abdomen  prominent,  especially  in  the 
median  line.  On  palpation  the' swelling  was  recognized  as  a  round,  smooth, 
fluctuating  tumor,  which  was  in  direct  contact  with  the  anterior  abdominal 
wall  and  could  be  moved  slightly  from  side  to  side.  Percussion  dullness  over 
the  entire  area  of  the  tumor.  Both  lumbar  regions  resonant.  Spleen  and 
kidney  dullness  normal.  A  vaginal  and  rectal  exploration  showed  that  the 
cervix  and  uterus  were  pushed  toward  the  right  side,  but  movable.  Behind  the 
uterus  a  firm  tumor  could  be  felt.  The  diagnosis  made  at  the  time  was 
unilocular  cyst  of  the  left  ovary. 

Laparotomy  was  performed  June  5,  1885.  Median  incision  exposed  the 
omentum  over  the  cyst,  slightly  adherent.  An  opening  was  made  in  the  omen- 
tum with  a  blunt  instrument,  through  which  the  cyst  wall  became  visible.  The 
hand  introduced  through  this  opening  showed  the  existence  of  firm  adhesions 
of  the  cyst  wall  to  neighboring  organs.  After  enlarging  the  external  incision 
the  gastro-colic  ligament  could  be  seen  stretched  over  the  cyst.  The  trans- 
verse colon  lined  the  lower  border  of  the  cyst,  and  had  descended  behind  the 
symphysis  pubis.  When  this  portion  of  the  intestine  was  elevated,  it  was  seen 
that  the  cyst  belonged  to  the  mesocolon.  The  separation  of  the  cyst  presented 
many  difficulties,  consequently  its  size  was  reduced  by  tapping,  the  opening 
was  closed  with  pressure  forceps,  and  enucleation  commenced  through  a 
vertical  slit  in  the  gastro-colic  ligament.  Numerous  ligatures  en  masse  had 
to  be  applied  to  arrest  troublesome  haemorrhage. 

1  Zur  Diagnostik  der  Pancreascyste,  Prag,  1886. 


CYSTS   OF  THE  PANCREAS.  381 

On  the  left  side  of  the  cyst  the  same  enlarged  vessel  was  met  with  that 
had  been  felt  externally;  it  was  found  so  intimately  adherent  to  the  cyst  wall 
that  it  conld  not  be  isolated;  a  double  ligature  was  therefore  made  around  it 
and  the  accompanying  vein,  and  the  vessel  divided  between  the  ligatures.  To 
facilitate  the  deep  dissection  the  incision  was  enlarged  upward,  and  the  cyst 
opened  and  emptied,  the  patient  lying  upon  the  side.  The  hand  was  intro- 
duced into  the  cyst,  when  it  was  found  that  the  attached  portion  extended  in 
an  upward  direction.  The  artery  previously  ligated  had  to  be  tied  again 
higher  up.  In  completing  the  tedious  enucleation  no  pedicle  was  found. 
From  the  position,  it  could  be  ascertained  that  the  base  of  the  cyst  was  in  the 
vicinity  of  the  pancreas. 

After  careful  arrest  of  haamorrhage  at  the  bottom  of  the  wound,  and  the 
usual  toilet  of  the  peritoneum,  the  external  wound  was  closed  completely,  no 
drainage  being  used.  The  patient,  who  had  become  considerably  collapsed, 
was  rallied  by  the  administration  of  stimulants.  In  the  evening,  temperature 
37.6°  C,  pulse  72,  pain  in  abdomen,  and  nausea.  Restless  during  the  night. 
During  the  next  few  days  the  pulse  became  more  frequent,  with  jaundice  and. 
diarrhoea,  great  restlessness  and  collapse,  which  terminated  in  death  on  the 
sixth  day  after  the  operation.  At  the  autopsy  extensive  purulent  peritonitis 
was  found  to  have  been  the  cause  of  death.  In  the  transverse  mesocolon  a 
hole  was  found,  through  which  a  fist  could  be  passed.  Through  this  opening 
a  cavity,  the  size  of  a  fist,  was  entered,  the  walls  of  which  were  infiltrated  with 
blood  and  pus.  In  the  bottom  of  this  cavity  the  exposed  pancreas  was  seen, 
which  appeared  divided  transversely  behind  the  head.  Along  the  margin  of 
the  pancreas  the  splenic  artery  and  vein  were  found  ligated,  and  a  portion  of 
both  vessels  excised.  The  middle  portion  of  the  pancreas  was  absent.  A 
portion  of  the  tail  of  the  organ,  five  centimeters  in  length,  remained.  Spleen 
enlarged  to  twice  its  normal  size,  otherwise  normal  in  structure.  Remaining 
organs  healthy.  A  microscopical  examination  of  the  cyst  showed  that  its  walls 
contained  pancreatic  tissue.     Inner  surface  not  lined  with  epithelial  cells. 

Case  4.  Reported  by  Kramer,  operation  performed  by  Hahn.1  Female, 
sixteen  years  of  age,  after  an  attack  of  vomiting  and  pain  in  the  abdomen, 
noticed  a  gradual  distention  of  the  upper  portion  of  the  abdominal  cavity. 
The  size  of  the  tumor  and  the  area  of  dullness  corresponding  were  about  the 
same  as  in  my  case.  The  dullness  appeared  to  be  continous  with  the  hepatic 
dullness.  Echinococcus  cyst  of  the  liver  was  diagnosticated.  Laparotomy 
was  performed,  and  the  omentum  divided  between  the  stomach  and  the  trans- 
verse colon.  About  two  litres  of  an  albuminous  fluid  were  removed  by  tapping. 
The  cyst  was  stitched  to  the  margin  of  the  abdominal  wound,  incised,  and 
drained.  The  patient  recovered  with  an  external  pancreatic  fistula,  which 
continued  to  secrete  pancreatic  juice  for  four  months. 

Remarks. — The  experiments  made  for  the  purpose  of  ascertain 
ing  the  effect  of  complete  and  permanent  obstruction  of  the  pancreal  Lo 
duct,  as  detailed  in  the  first  part  of  the  paper,  have   demonstrated 

1  Centralblatt  fur  Chirurgie,  No.  2,  1885. 


682  EXPERIMENTAL  SURGERY. 

conclusively  that  obstruction  is  not  the  only,  nor  the  most  important 
element  in  the  causation  of  a  pancreatic  cyst.  That  the  ligated 
portion  of  the  pancreas  continued  to  secrete  pancreatic  juice  was 
demonstrated  by  the  experiments  on  external  pancreatic  fistulae,  and 
yet,  of  the  many  cases  of  ligation  of  the  pancreas,  in  not  a  single 
instance  was  a  cyst,  or  even  an  attempt  at  the  formation  of  a  cyst, 
observed.  The  only  physical  evidence  of  obstruction  was  apparent 
in  a  moderate  and  uniform  dilatation  of  the  duct  behind  the  ligature. 
The  most  important  etiological  factor  in  cases  of  cysts  of  the  pan- 
creas must  be  sought  in  an  arrest  of  absorption  of  the  pancreatic 
juice,  due  either  to  a  transformation  of  the  pancreatic  juice  by  the 
admixture  of  pathological  products,  into  a  substance  which  is  incap- 
able of  being  absorbed,  or  to  a  loss  of  function  in  this  direction,  of  the 
vessels  which  perform  this  task. 

The  obstruction  in  the  pancreatic  duct  may  cause  retention  and 
accumulation  of  pathological  products,  but  can  never  be  the  sole 
cause  of  retention  of  pancreatic  juice  in  an  otherwise  healthy  portion 
of  the  pancreas.  In  the  cases  where  normal  pancreatic  tissue  was 
found  in  the  cyst  walls,  it  was  more  than  probable  that  the  pathologi- 
cal condition  which  had  caused  the  obstruction  did  not  effect  com- 
plete physiological  detachment  of  the  peripheral  portion  of  the 
pancreas ;  in  other  words,  the  obstruction  was  not  complete.  In  cases 
where  complete  physiological  detachment  has  taken  place,  either  by 
the  application  of  a  ligature,  or  complete  obliteration  of  the  duct  by 
pathological  conditions,  parenchymatous  degeneration  and  atrophy 
in  the  detached  portion  are  such  constant  results,  that  the  exceptions 
to  this  rule  must  indeed  be  few,  if  any. 

To  the  diagnosis  of  pancreatic  cysts  nothing  new  has  been 
added.  The  history  of  the  case,  the  primary  starting-point  of  the 
tumor  in  the  epigastric  region,  its  gradual  and  almost  painless 
growth,  are  points  which  should  be  carefully  considered  in  the 
differential  diagnosis  of  abdominal  cysts.  The  treatment  by  extir- 
pation, as  only  recently  practiced  again  by  Riedel  and  Billroth,  is 
not  deserving  of  imitation, 

The  post-mortem  examination  in  Billroth's  case  shows  only  too 
plainly  the  difficulties  met  with  in  identifying  the  tissues  at  such 
great  depth,  and  the  difficulty  of  avoiding  unnecessary  injury  to 
important  structures.  Extirpation  of  the  cyst  would  guard  most 
effectually  against  the  formation  of  a  permanent  pancreatic  fistula, 


TUMORS   OF   THE   PANCREAS.  383 

but,  on  account  of  the  deep  location  of  the  pancreas,  the  shortness  or 
absence  of  a  pedicle,  and  the  many  obstacles  thrown  in  the  way  of 
the  operator  by  adjacent  organs,  the  procedure  becomes  one  sur- 
rounded by  innumerable  difficulties  and,  in  the  present  state  of  our 
science,  of  doubtful  propriety. 

The  formation  of  an  external  pancreatic  fistula  in  the  treatment 
of  cysts  of  the  pancreas  has  been  so  uniformly  successful  that  it 
should  be  invariably  adopted  in  preference  to  excision.  The  latter 
operation  should  only  be  resorted  to  in  cases  where  portions  of  the 
cyst  wall  have  become  the  seat  of  malignant  disease,  and  in  cases 
where  life  is  threatened  by  haemorrhage  into  a  cyst  by  the  rupture 
of  vessels  lining  the  interior  of  the  cyst,  which  cannot  be  controlled 
by  simpler  and  less  hazardous  measures. 

XII.     Tumors  of  the  Pancreas. 

i.     Hypertrophy. 

Case  1.  Storck l  mentions  a  case  of  intestinal  obstruction  caused  by 
hypertrophy  of  the  pancreas.  A  man,  forty-eight  years  of  age,  previously  in 
good  health,  had  felt  a  sensation  of  weight  and  distress  after  meals,  for  more 
than  six  months.  The  flatulency  also  caused  distress,  and  was  relieved  at  times 
by  drinking  large  quantites  of  water.  Bowels  constipated.  The  symptoms 
of  obstruction  developed  gradually,  but  finally  became  so  severe  that  nothing 
was  retained  on  the  stomach.  After  obstruction  had  become  complete,  the 
patient  became  collapsed  and  died  two  days  later.  At  the  autopsy  no  signs  of 
inflammation  or  effusion  in  the  peritoneal  cavity  could  be  found.  The  head 
of  the  pancreas,  which  was  enlarged  to  the  size  of  an  orange,  had  so  com- 
pletely compressed  the  duodenum  that  its  lumen  would  only  permit  the 
passage  of  a  goose  quill.  The  pyloric  portion  of  the  stomach  was  enormously 
dilated,  so  that  this  pouch  resembled  a  kind  of  lesser  stomach.  The  pancreas 
was  softer,  more  succulent,  and  fleshier  than  normal,  but  not  at  all  indurated. 

Remarks. — As  no  microscopical  examination  of  the  tumor  was 
made,  we  are  unable  to  classify  this  case,  but  considerable  doubt 
must  remain  whether  it  was  a  case  of  tumor  or  simple  hyperplasia 
of  the  gland.  The  age  of  the  patient  and  the  effect  of  the  tumor 
upon  the  duodenum  make  it  quite  probable  that  it  was  not  a  case  of 
hypertrophy,  but  rather  one  of  carcinoma  or  sarcoma.  The  case 
illustrates  the  fact  that  tumors  of  the  pancreas,  when  they  occupy 
the  head  of  the  organ,  are  liable  to  produce  intestinal  obstruction  by 
compression. 

'Annus  Medicus,  1836;  Schmidt's  Jphrbfloher,  Supp.  Band,  1836,  p.  161. 


384  EXPERIMENTAL  SURGERY. 


2.    Sarcoma. 


Of  the  malignant  tumors  of  the  pancreas,  carcinoma  is  of  much 
greater  frequency  than  sarcoma.  Only  a  very  few  cases  of  primary 
sarcoma  of  the  pancreas  are  on  record. 

Case  2.  Mayo 1  mentions  a  case  of  primary  sarcoma  of  the  pancreas,  with 
secondary  invasion  of  the  stomach,  that  came  under  his  care.  The  patient,  a 
man  aged  thirty-five  years,  died  after  an  obscure  illness  which  lasted  eight 
months,  during  which  time  it  was  impossible  to  locate  the  disease.  He  dated 
his  illness  back  to  a  febrile  attack,  which  left  him  in  a  debilitated  condition; 
and  from  that  time  he  was  liable  to  dyspeptic  symptoms,  with  variable  appe- 
tite and  undefined  uneasiness  in  the  epigastric  region.  A  high  degree  of 
anaemia  was  a  conspicuous  symptom  during  life.  Although  the  appetite 
remained  good,  and  digestion  did  not  appear  to  be  very  much  impaired, 
emaciation  progressed  rapidly.  On  inspection  all  the  internal  parts  were 
found  extremely  pale,  and  void  of  blood;  the  heart  healthy,  but  nearly  empty. 
The  pylorus  was  thickened  and  firmer  than  usual,  and  had  contracted  adhesions 
to  the  pancreas.  The  pancreas  was  considerably  enlarged  and  of  nearly  carti- 
laginous hardness,  except  in  some  spots,  which  were  soft,  with  the  appearance 
of  medullary  sarcoma.  No  other  disease  could  be  detected  in  any  other  part 
of  the  body. 

Case  3.  Lepine  and  Cornil2  examined  the  body  of  a  man,  sixty-two 
years  of  age,  who  had  been  sick  for  eleven  months,  and  had  suffered  from 
obstinate  vomiting  for  seven  months.  The  head  of  the  pancreas  was  found 
very  much  enlarged;  the  remaining  portion  of  it  was  normal.  The  small 
curvature  of  the  stomach  was  adherent  to  the  tumor,  the  pyloric  orifice  thick- 
ened and  its  lumen  narrowed.  The ,  adhesions  involved  also  the  liver, 
diaphragm,  and  lower  surface  of  the  lung.  White  metastatic  nodules  were 
found  in  both  kidneys.  Under  the  microscope,  sections  of  the  tumor  revealed 
a  sarcomatous  structure. 

Remarks. — In  the  two  cases  related  here,  we  have  the  principal 
types  of  the  clinical  behavior  of  sarcomatous  tumors.  In  the  first 
case  the  disease  involved  almost  the  entire  organ,  having  given  rise 
to  extensive  local  destruction  without  metastasis ;  in  the  second  case 
the  disease  was  limited  locally  to  the  head  of  the  pancreas,  while  it 
had  extended  early  by  contiguity  to  adjacent  organs,  and  by  metas- 
tasis to  distant  organs. 

Friedreich*  claims  that  at  present  we  are  acquainted  with  only 
one  single  reliable  case  of  primary  sarcoma  of  the  pancreas.  It 
is  described  by  Paulick,  and  was  found  to   be  of  the  small-celled 


1  Outlines  of  Human  Pathology,  p.  411. 

2  Contrib.  a  l'anatom.  path,  du  pancreas,  Gaz.  Med.  de  Paris,  1874,  p.  624. 

3  Ziemssen's  Cyclopaedia,  vol.  viii.  p.  614. 


TUMORS   OF   THE   PAX  ORE  AS.  385 

variety:  it  was  taken  from  the  body  of  a  young  man  who  had  died  of 
pulmonary  and  intestinal  phthisis.  It  had  not  given  rise  to  any 
noticeable  symptoms  during  life. 

3.     Carcinoma. 

# 

It  is  claimed  by  some  pathologists  that  primary  cancer  of  the 
pancreas  is  an  exceedingly  rare  affection,  and  that  in  the  majority  of 
cases  where  this  organ  is  the  seat  of  the  lesion,  it  occurs  as  a  secondary 
affection,  having  reached  it  by  extension  from  an  adjacent  organ, 
especially  from  the  pyloric  extremity  of  the  stomach.  While  this 
may  be  true  in  many  cases,  quite  a  number  of  specimens  have  been 
examined  where  the  disease  occurred  here  as  a  primary  affection. 

Suche1  appears  to  have  examined  a  specimen  which  affords  a 
good  illustration  of  primary  cancer  of  the  body  of  the  pancreas. 
The  middle  of  the  gland  was  converted  into  a  hard,  irregular, 
nodulated  mass  the  size  of  a  fist,  which  rested  directly  upon  the 
aorta  which  imparted  to  it  pulsation  during  life.  When  cut  into, 
the  tumor  grated  under  the  knife,  and  the  cut  surfaces  presented  a 
laminated  appearance.  The  substance  of  the  tumor  was  traversed 
by  numerous  large  veins;  both  extremities  of  the  pancreas  were 
healthy,  and  no  secondary  nodules  could  be  found  in  any  portion  of 
the  body. 

A  primary  cancer  of  the  pancreas  is  also  described  by  Schup- 
niair,  where  the  tumor  had  formed  adhesions  with  the  spleen,  while 
the  liver  contained  a  number  of  metastatic  deposits.  The  terminal 
extremity  of  the  pancreatic  duct  contained  a  cylindrical  calculus 
with  a  number  of  arborescent  projections,  which  corresponded  to  the 
contributory  ducts.  In  another  case,  reported  by  R^camier/  the 
cancerous  tumor,  which  involved  the  tail  of  the  pancreas,  was  con- 
nected with  the  left  kidney  and  compressed  the  ureter.  The  right 
half  of  the  pancreas  was  healthy,  the  diseased  portion  gray,  hard, 
and  lardaceous.  The  pelvis  of  the  left  kidney,  in  consequence  of 
the  compression  of  the  ureter,  was  hydronephrotic.  The  remaining 
organs  were  healthy. 

Bright,  in  1832,  reported  a  number  of  cases  of  primary  carci- 
noma of  the  pancreas,  with  a  special  view  of  illustrating  the  effect 

1  De  Scirrho  pancreat.  nonnula,  Dissert.     Berol.,  1834. 

2  Hafeland's  Journal,  1841. 

3  Revue  Medical,  1830. 

25 


386  EXPERIMENTAL   SURGERY. 

which  disease  of  this  organ  would  have  upon  the  digestion  of  fat. 
In  three  out  of  eight  cases  he  noticed  fatty  diarrhoea,  and  he  was 
inclined  to  the  belief  that  this  symptom,  when  present,  is  almost 
pathognomonic  of  the  existence  of  disease  of  the  pancreas.1 

In  all  cases  the  fatty  diarrhoea  was  associated  with  jaundice. 
The  following  post-mortem  account"  leaves  no  doubt  that  the  disease 
was  primarily  limited  to  the  pancreas:  "  The  cause  of  the  pressure 
on  the  bile-ducts  was  immediately  obvious;  for,  on  placing  the  hand 
near  the  pylorus,  a  hard  lump,  of  the  size  of  a  common  egg,  was 
easily  felt,  and  was  soon  discovered  to  be  the  head  of  the  pancreas 
itself,  and  not  the  glands  surrounding  that  part,  forming  a  yellow 
mass  like  the  boiled  udder  of  a  cow,  almost  cartilaginous  in  hard- 
ness. Its  texture  was  uniformly  hard  and  unyielding,  and  the  whole 
pancreas  partook  of  the  same,  but  in  a  less  degree.  The  head  of 
the  pancreas  was  firmly  and  inseparably  glued  to  the  duodenum, 
and  the  hardness  very  nearly  surrounded  the  viscus." 

As  undoubted  instances  of  primary  cancer  of  the  pancreas,  we 
must  mention  the  following  cases: 

Albers.  Med.  Correspbl.  rhein  u.  westf.  Arzte,  No.  8,  1843. 

Bowditch.     Boston  Medical  and  Surgical  Journal,  July,  1872. 

Davidsohn.     Ueber  Krebs  der  Bauchspeicheldriirse,  Dissert.,  Berlin,  1872. 

Frerichs.     Klin.  d.  Leberkrankheiten,  vol.  i.  pp.  146  and  153. 

Friedreich.     Diseases  of  the  Pancreas.     Ziems.  Cyclop.,  vol.  viii,  p.  608. 

Gross.     Philadelphia  Medical  Times,  vol.  ii.  June,  1872. 

Haldauer.     Assoc.  Medical  Journal,  May,  1854. 

Luithlen.     Mem.  a.  d.  artzl.  Praxis.  1872,  vol.  xvii,  p.  309. 

Muehry.     Casper's  Wochenschrift.  No.  10,  1835. 

Roberts.     British  Medical  Journal,  September,  1865. 

Wagner.     Archiv.  der  Heilkunde.  vol.  ii.  p.  285. 

Webb.     Philadelphia  Medical  Times,  vol.  ii.  December,  1871. 

Williams.     Medical  Times  and  Gazette,  August,  1852. 

According  to  Da  Costa,*  cancer  of  the  pancreas  is  more  frequent 
in  the  male  than  in  the  female,  and  in  preference  attacks  people 
more  than  forty  years  of  age.  It  usually  appears  as  a  firm  tumor 
or  scirrhus,  with  a  well-developed  connective  tissue  reticulum. 
Other  varieties  of  carcinoma  have  been  described.     Thus,  Wagner 

1  Cases  and  Observations  Connected  with  Disease  of  the  Pancreas, 
Medico-Chirurgical  Transactions,  vol.  xviii.  p.  1. 

2  Ibid,  p.  17. 

3  North  Am.  Med.  Chir.  Review,  September.  1858. 


T-L'MOBS   OF   THE   PANCREAS.  387 

observed  a  cylindroma,  and  Liicke  and  Klebs  have  each  met  with 
the  colloid  variety.  The  primary  starting-point  is  usually  in  the 
head  of  the  organ,  whence  it  extends  in  all  directions.  By  exten- 
sion within,  it  successively  invades  the  body  and  tail  of  the  organ, 
until  the  whole  gland  is  involved,  when  it  forms  a  nodulated 
spherical  tumor.  . 

The  extension  of  the  growth  in  an  opposite  direction  soon 
reaches  the  duodenum,  where  it  produces  a  narrowing  or  complete 
stenosis  of  that  portion  of  the  intestinal  canal.  A  case  of  this  kind 
is  related  by  Hoelscher,  where  the  duodenum  was  constricted  to  such 
an  extent  that  it  was  entirely  impermeable,  and  the  patient  suffered 
for  several  days  from  symptoms  of  intestinal  obstruction.  While 
cancer  of  the  stomach  is  liable  to  extend  to  the  pancreas,  the  reverse 
is  not  frequently  observed.  When  the  carcinoma  develops  primarily 
in  the  pancreatic  ducts,  it  belongs  to  the  variety  called  cylindroma. 
The  lymphatic  glands  in  the  vicinity  of  the  pancreas  are  invariably 
affected  during  the  later  stages  of  the  disease. 

4.     Symptoms  and  Diagnosis. 

Stearrhoea  is  an  important  but  not  infallible  symptom  of  cancer 
of  the  pancreas.  It  is  attributed  to  an  absence  of  the  pancreatic 
juice  in  the  intestinal  canal,  caused  either  by  obstruction  in  the  duct 
or  suspension  of  the  physiological  function  of  the  organ  by  the 
neoplastic  infiltration.  Epigastric  pain  is  an  early  and  important 
symptom,  and  is  the»result  of  compression  of  the  cceliac  plexus  by 
the  tumor.  The  pain  often  assumes  a  neuralgic  character,  and  is 
usually  not  aggravated  after  taking  food.  Vomiting  is  a  frequent 
symptom,  and  the  matter  ejected  is  generally  a  watery  fluid,  some- 
times stained  with  bile.     Constipation  is  an  almost  constant  symptom. 

Progressive  emaciation  and  anaemia  attend  malignant  disease  in 
any  locality,  but  are  unusually  well  marked  in  cancer  of  the  pancreas. 
When  the  disease  extends  toward  the  duodenum,  jaundice  occurs 
from  stenosis  of  the  bile-ducts  by  compression  or  direct  invasion  by 
the  neoplasm.  Bruen  has  called  attention  to  some  forty  cases  of 
jaundice  due  to  primary  carcinoma  of  the  head  of  the  pancreas, 
lately  reported  by  another  observer,  from  which  it  is  demonstrated 
that  jaundice  is  an  invariable  symptom  of  primary  scirrhus  of  the 
bead  of  the  pancreas,  while  it  is  uncommon  when  the  disease  is 
Becondary,  or  affects  the  body  or  tail  of  the  organ. 


388  EXPERIMENTAL   SURGERY. 

The  most  reliable  evidence  is  the  appearance  of  a  tumor  in  the 
epigastrium,  behind  the  stomach.  The  difficulty  of  examining  the 
pancreas  during  health  by  palpation  is  appreciated  when  a  physical 
examination  is  to  be  relied  upon  in  locating  tumors  in  this  locality: 
The  normal  pancreas  can  be  felt  only  under  the  most  favorable  con- 
ditions through  a  thin  and  relaxed  abdominal  wall,  but  in  determining 
its  relative  size  this  method  of  examination  affords  but  little  reliable 
information.  A  cancer  of  the  pancreas,  when  it  can  be  felt  by  palpa- 
tion, appears  in  the  epigastrium  as  a  hard,  immovable  or  only  slightly 
movable  tumor,  which  is  evidently  deeply  seated  in  the  abdominal 
cavity. 

Under  favorable  conditions  the  connections  of  such  a  tumor  with 
the  pancreas  can  sometimes  be  demonstrated  during  life,  but  a  posi- 
tive diagnosis  becomes  impossible  when,  as  in  most  of  the  cases 
hitherto  recorded,  it  constitutes  merely  a  part  of  a  general  tumefac- 
tion of  the  abdomen.  As  the  tumor  is  in  such  close  proximity  to  the 
abdominal  aorta,  the  pulsations  of  this  vessel  are  imparted  to  the 
tumor,  and  a  bruit  may  even  be  heard  over  the  compressed  vessel; 
but,  in  contradistinction  to  aneurism,  the  pulsation  is  felt  in  only  one 
direction,  and  the  bruit  disappears  when  the  patient  is  placed  in  the 
knee-elbow  position,  as  the  tumor  is  lifted  from  the  vessel  by  the 
force  of  gravitation. 

That  the  tumor  cannot  be  always  felt  is  evident  from  the  state- 
ment made  by  Da  Costa  that  he  recognized  it  in  only  thirteen  out  of 
the  one  hundred  and  thirty- seven  cases  he  reported;  and  Bigsby,  in 
an  analysis  of  fifteen  cases,  alludes  to  its  being  recognized  in  only 
four. 

From  what  has  been  said  it  will  be  seen  how  uncertain  the 
symptoms  are  in  the  diagnosis  of  cancer  of  the  pancreas.  A  satis- 
factory conclusion  can  be  reached  only  after  a  careful  consideration 
of  the  history  of  the  case  combined  with  a  systematic  elucidation  of 
all  the  symptoms  presented,  and  more  particularly  by  resorting  to 
the  advantages  to  be  derived  from  a  systematic  and  careful  study  by 
exclusion. 

5.     Treatment. 

A  positive  diagnosis  of  malignant  disease  of  the  pancreas  is 
only  possible  after  the  tumor  has  attained  sufficient  size  to  be  recog- 
nizable by  palpation,  consequently  too  late  for  a  radical  extirpation. 


TUMORS   OF   THE   PANCREAS.  389 

When  the  disease  has  advanced  to  this  stage  it  has  already  involved 
the  greater  portion  of  the  gland  and,  as  a  rule,  has  invaded  important 
adjacent  organs.  Another  important  element  in  the  surgical  treat- 
ment of  cancer  of  the  pancreas  consists  in  the  fact  that  the  disease, 
as  a  rule,  develops  primarily  in  the  head  of  the  organ,  a  location 
•which,  in  itself,  precludes  the  propriety  of  an  operation. 

The  most  favorable  conditions  for  extirpation  are  presented  if 
the  disease  is  primarily  located  in  the  tail  of  the  pancreas,  and  has 
not  passed  beyond  the  limits  of  the  capsule  of  the  gland.  In  such 
a  case,  excision  of  the  splenic  extremity  of  the  pancreas  would  offer 
a  fair  prospect  for  a  permanent  result  without  endangering,  as  a 
remote  consequence,  the  process  of  digestion,  as  a  sufficient  amount 
of  secreting  structure  would  remain  in  connection  with  the  intestine 
to  maintain  pancreatic  digestion. 

Billroth,  in  two  instances,  made  a  partial  resection  of  the  pan- 
creas in  removing  carcinomatous  tumors  of  adjacent  organs.  In  one 
case  he  removed  a  portion  of  the  head  of  the  pancreas  with  a  cancer 
of  the  pylorus,  and  in  another  case  he  removed  the  tail  of  the  pan- 
creas with  a  sarcomatous  spleen.  Both  patients  recovered  from  the 
immediate  effects  of  the  operation.  In  the  case  of  partial  excision 
of  the  head  of  the  pancreas  it  is  to  be  assumed  that  the  duct  was 
not  injured,  that  the  organ  continued  to  secrete,  and  that  the  pan- 
creatic juice  was  discharged  into  the  duodenum  through  the  unin- 
jured duct.  In  operating  upon  the  head  of  the  pancreas  for 
malignant  disease  which  has  extended  to  it  from  an  adjacent  organ, 
it  is  essential  to  preserve  the  continuity  of  the  duct,  so  as  to  prevent 
physiological  detachment  of  the  remaining  portion  of  the  gland,  an 
accident  which  would  be  followed  by  degeneration  and  complete 
atrophy,  consequently  suspension  of  pancreatic  digestion. 

If  an  operation  is  performed  for  cancer  of  an  adjacent  organ, 
and  the  disease  has  extended  to  the  splenic  extremity  of  the  gland, 
the  operation  should  not  be  completed  without  removing  a  sufficient 
portion  of  the  pancreas  to  guard  against  a  local   recurrence  of  the 

36  in  tli is  organ.     As  in  cases  of  partial  excision  of  the  pan- 

for  other  lesions,  the  pancreas  should  be  ligated  before  it  is 

divided,  so  as  to  prevent  troublesome  haemorrhage,  and  at  the  same 

time  guard  against   extravasation  of   pancreatic,  juice  into  the  peri- 

toneal  cavity. 


390  EXPERIMENTAL  SURGERY. 

XIII.    Tuberculosis  of  the  Pancreas. 

Primary  tuberculosis  of  the  pancreas  is  an  exceedingly  rare 
affection;  indeed,  some  pathologists,  among  them  Louis  and  Lebert, 
doubt  its  primary  origin  in  this  organ.  Cruveilhier  only  mentions 
tubercular  degeneration  of  the  lymphatic  glands  upon  the  surface  of 
the  pancreas.  In  diffuse  miliary  tuberculosis  of  the  abdominal 
organs  Klebs  could  find  no  nodules  in  the  substance  of  the  pancreas 
on  microscopical  examination.  But  in  such  a  condition  the  gland  is 
often  found  in  a  state  of  parenchymatous  degeneration,  which  has 
been  incorrectly  interpreted  by  Ancelet,  as  the  first  stage  of  tuber- 
culosis. 

When  the  lymphatic  glands  around  the  pancreas  have  undergone 
cheesy  degeneration  we  sometimes  find  similar  deposits  in  the  pan- 
creas, which,  however,  may  be  cheesy  lymphatic  glands  in  the 
substance  of  the  pancreas  itself.  Hartmann  mentions  a  case  where 
the  pancreas  had  disappeared  completely  and  its  place  was  occupied 
by  a  cheesy  mass.  Although  the  pancreas  is  not  disposed  to  tuber- 
culosis, we  have  reliable  information  that  in  a  number  of  cases  this 
gland  was  the  primary  seat  of  the  process. 

Case  1.  Reported  by  Aran.1  The  patient  was  a  woman,  twenty-five  years 
of  age,  who  died  of  a  lingering  disease.  She  had  been  sick  for  a  year,  during 
which  time  she  felt  exceedingly  weak,  had  frequent  attacks  of  vomiting,  and 
the  skin  became  deeply  bronzed,  in  some  places  almost  black.  The  pain, 
which  was  severe  at  times,  was  referred  to  the  epigastrium.  The  necropsy 
showed  a  tubercular  deposit  in  the  tail  of  the  pancreas,  the  size  of  a  hen's  egg, 
surrounded  by  a  zone  of  miliary  deposits  in  the  substance  of  the  gland. 
Miliary  tubercles  were  also  found  in  the  spleen. 

Case  2.  Mayo  2  describes  a  case  where  we  have  reason  to  believe  that  the 
process  commenced  primarily  in  the  pancreas.  The  patient  was  an  inmate 
of  Middlesex  Hospital,  and  was  under  the  care  of  Dr.  Wilson.  He  was  thirty- 
eight  years  of  age  and  had  been  ill  for  sixteen  weeks;  during  the  last  seven 
weeks  he  was  confined  to  his  bed.  The  first  symptoms  were  pain  in  the  abdo- 
men extending  along  the  right  hypochondrium  to  the  spine.  Twenty-eight 
days  before  death  he  became  jaundiced,  stools  white,  urine  high  colored;  for 
some  time  he  could  lie  on  the  right  side  only,  and  was  often  obliged  to  sit 
upright  to  draw  breath.  A  large  abdominal  tumor  had  been  felt  immediately 
above  the  umbilicus  some  time  before  death,  and  the  right  arm  and  side  of  the 
neck  had  become  cedematous. 

1  Archives  generates  de  Medecine,  1846. 

2  Outlines  of  Human  Pathology,  p.  410. 


LIPOMATOSIS   OF  THE  PANCREAS.  39] 

Autopsy:  Serous  effusion  in  to  the  right  pleural  cavity.  The  gall-bladder 
was  distended  to  a  great  size  so  that  it  contained  eight  ounces  of  fluid.  The 
distention  arose  from  an  enlargement  of  the  pancreas,  the  head  of  which 
formed  an  irregular  sphere  four  inches  in  diameter,  which  had  compr<  ssed 
the  gall-duct;  the  rest  of  the  gland  was  also  enlarged.  In  parts  it  presented 
its  natural  texture  and  color,  at  other  parts  it  was  infiltrated  witli  tubercular 
matter,  which  at  two  or  three  points  had  softened  and  formed  thick  pus.  A 
few  lymphatic  glands,  the  thymus  gland,  and  kidneys,  appeared  to  be  secon- 
darily involved. 

Remarks. — Although  in  both  of  these  cases  the  symptoms  during 
life  pointed  to  disease  of  the  pancreas,  a  sufficiently  positive  diagnosis 
to  warrant  a  laparotomy  could  only  have  been  made  after  a  palpable 
tumor  appeared,  and  after  this  time  the  disease  had  already  passed 
beyond  reach,  by  the  appearance  of  miliary  deposits  in  other  organs, 
an  occurrence  which  would  preclude  the  justifiability  of  any  operative 
interference.  Should  abdominal  section  be  performed  in  a  case  of 
tubercular  peritonitis,  and  should  such  a  condition  in  the  pancreas 
be  found  as  in  Aran's  case,  it  would  be  proper  to  extirpate  the 
terminal  end  of  the  pancreas  inclusive  of  the  tubercular  abscess. 

In  Wilson's  case  the  tubercular  deposit  in  the  pancreas  gave 
rise  to  a  large  abdominal  tumor,  due  partly  to  the  distended  gall- 
bladder, and  as  such  a  condition  might  present  itself  to  the  surgeon, 
in  these  days  of  diagnostitial  laparotomy,  it  might  be  advisable,  and 
to  the  advantage  of  the  patient,  to  establish  an  external  pancreatic 
fistula  instead  of  closing  the  wound.  Such  a  course  would  enable 
the  surgeon  to  remove  the  cheesy  material,  disinfect  the  abscess 
cavity,  and  to  treat  its  interior  with  iodoform,  all  of  which,  done 
under  antiseptic  precautions,  would  tend  to  modify  favorably  the 
local  process. 

The  removal  of  compression  of  the  bile-duct  by  the  same  pro- 
cedure would  also  tend  to  reestablish  the  interrupted  communication 
between  the  bile-ducts  and  the  duodenum  by  removing  the  cause  of 
the  stenosis. 

XIV.     Lipomatosis  of  the  Pancreas. 

Lipomatosis,  or  fatty  infiltration  of  the  pancreas,  is  a  patho- 
logical condition  of  this  organ  which  is  characterized  by  a  transfor- 
mation of  the  interacinous  connective  tissue  into  fat,  in contradistii lc- 
tion  to  fatty  degeneration  of  the  parenchyma  cells,  which  sometimes 
occurs  as  an  imle|>"mleiit  affection.      In  cases  of  fatty  infiltration  the 


392  EXPERIMENTAL  SURGERY. 

shape  and  size  of  the  pancreas  may  remain  normal,  but  the  secreting 
structures  themselves  may  have  completely  disappeared  by  pressure- 
atrophy.  This  disease  is  of  little  interest  to  the  surgeon,  except  that 
it  may  serve  as  a  predisposing  cause  of  interstitial  haemorrhage,  in 
which  connection  it  has  already  received  mention;  it  is  here  again 
alluded  to  as  a  separate  affection,  to  demonstrate  that  gradual 
atrophy  of  the  pancreas,  even  to  the  extent  of  complete  disappear- 
ance of  the  glandular  structures,  may  occur  without  causing  serious 
impairment  of  the  digestion. 

Rokitansky '  has  found  this  condition  of  the  pancreas  generally 
as  a  part  and  parcel  of  a  general  obesity,  especially  in  intemperate 
persons,  together  with  fatty  liver,  heart,  and  omentum.  In  the 
thr.ee  cases  of  pancreatic  apoplexy  described  by  Zenker,  the  fatty 
infiltration  of  the  pancreas  was  only  one  of  the  many  evidences  of  a 
diffuse  malnutrition  of  the  tissues.  In  some  of  these  cases  the 
patients  exhibited  no  symptoms  during  life  indicating  the  absence 
of  the  pancreatic  secretion,  and  yet  on  making  the  post-mortem 
examinations,  complete  destruction  of  the  glandular  structure  was 
found. 

Litten2  has  reported  three  cases  of  complete  atrophy  of  the 
pancreas  in  which,  during  life,  no  symptom  of  pancreatic  disease, 
such  as  fatty  stools,  salivation,  lipuria,  bronzed  skin,  cceliac  neuralgia, 
etc.,  was  observed.  In  two  cases  the  atrophy  was  due  to  pressure, 
and  in  one  instance  it  was  caused  by  primary  cancer  of  the  pancreas. 

In  other  cases  the  suspension  of  the  pancreatic  function  by 
fatty  degeneration  of  the  organ  produces  well-marked  symptoms 
during  life,  and  may  even  result  in  death.  Such  a  case  is  reported 
by  L6pine  and  Cornil.3  The  patient  was  a  drunkard,  fifty-seven 
years  of  age.  For  six  months  he  had  been  ailing  with  indigestion, 
marked  loss  of  weight,  diarrhoea  alternating  with  constipation,  no 
fever,  no  vomiting.  For  two  months  his  body  was  covered  with  an 
eruption,  and  his  feet  became  oedematous.  At  the  autopsy  the 
pancreas  was  found  normal  in  size  and  shape,  bixt  the  parenchyma 
of  the  gland  had  entirely  disappeared,  and  its  place  was  occupied 
by  adipose  tissue.     The  pancreatic  ducts  were  filled  with  a  viscid 

1  Lehrbuch  der  path.  Anat.,  vol.  iii.,  pp.  313  and  369. 

2  Charite  Annalen,  1881. 

3  Gazette  Medicale  de  Paris,  p.  624. 


L1THIASIS   OF  PANCREATIC  DUCTS.  393 

whitish  thud  and  small  concretions.  No  other  cause  of  death  could 
be  found  in  any  of  the  remaining  organs.  Clinical  observation 
appears  to  confirm  the  results  obtained  by  experiments  on  animals, 
that  in  some  instances  complete  gradual  atrophy  of  the  pancreas  is 
compatible  with  normal  digestion,  while,  in  other  cases,  the  suspen- 
sion of  the  pancreatic  secretion  is  followed  by  serious  disturbance  of 
digestion,  marasmus,  and  death  from  inanition. 

The  only  plausible  explanation  of  the  different  effects  of  the 
same  cause  can  be  found  in  the  supposition  that  in  some  individuals, 
the  compensating  function  of  vicarious  organs  maintains  normal 
digestion,  while  in  others  no  such  compensating  action  is  estab- 
lished. 

XV.     Lithiasis  of  Pancreatic  Ducts. 

Concretions  of  carbonate  and  phosphate  of  lime  are  frequently 
found  in  the  pancreatic  ducts.  They  are  usually  multiple,  small, 
whitish,  smooth,  or  of  rough  and  irregular  shape.  Calculi  in  this 
locality  have  been  found  which  measured  more  than  an  inch  in 
diameter.  In  Schupman's  case,  the  calculus  weighed  two  hundred 
grains  an^  measured  one  and  a  half  Paris  inches  in  length,  and  from 
rive  to  six  Paris  lines  in  diameter;  having  a  crystalline  surface,  with 
processes  running  into  smaller  ducts.  It  was  found  in  the  left 
extremity  of  Wirsung's  duct. 

Sometimes  concretions  of  calcium  phosphate  and  carbonate 
exist  in  cases  of  incrustation  of  the  mucous  lining  of  the  ducts. 
According  to  Collard  de  Martigny,  the  calculous  concretion  is  some- 
times composed  of  phosphate  of  lime  alone.  The  calculi  in  this 
locality  are  usually  solid  formations,  of  line  granular  structure  with 
somewhat  rough  surfaces,  and  are  very  often  covered  with  sharp 
points  of  projection.  In  some  specimens  the  stone  presents  numer- 
ous branches  which  correspond  to  smaller  pancreatic  ducts.  The 
irritation  incident  to  the  presence  of  a  calculus  in  the  pancreatic 
duct  is  followed  by  consecutive  pathological  changes  in  the  duct  and 
glandular  tissue  of  the  organ  itself.  The  substance  of  the  organ  in 
the  immediate  vicinity  of  the  stone  becomes  the  seat  of  interstitial 
inflammation,  followed  by  atrophy  and  sclerosis ;  the  cicatricial  tissue 
produced  by  this  change  causes  contraction,  an  occurrence  which 
may  still  further  aggravate  the  obstruction. 


394  EXPERIMENTAL   SURGERY. 

In  some  instances  this  inflammatory  process  does  not  remain 
localized,  but  extends  over  the  entire  gland,  as  in  the  cases  observed 
by  Engel,  Elliotson,  and  Curnow.  In  some  cases  the  concretion 
gives  rise  to  suppuration,  as  in  Portal's  case.  His  patient  had  died 
suddenly  with  symptoms  of  aneurism  of  the  aorta,  and  at  the  autopsy 
an  abscess  was  found  in  the  head  of  the  pancreas,  which  contained  a 
number  of  biliary  and  pancreatic  calculi.  In  Fauconneau-Dufresne's 
case,  as  quoted  by  Ancelet,  the  left  half  of  the  pancreas  contained  a 
number  of  abscesses,  one  of  which  had  perforated  into  the  stomach. 
The  pus  contained  numerous  concretions  varying  in  size  from  a  pin's 
head  to  that  of  a  bean.  Salmade  observed  a  case  of  lithiasis  compli- 
cated with  abscess  of  the  pancreas,  where  the  swelling  compressed 
the  underlying  aorta  to  such  an  extent  that  death  was  produced  by 
the  rupturing  of  a  vessel  from  over- distention  on  the  proximal  side 
of  the  obstruction. 

Mr.  Norman  Moore1  presented  to  the  Pathological  Society  of 
London  the  pancreas  of  a  man,  aged  forty-three  years,  who  died  in 
St.  Bartholomew's  Hospital  of  an  attack  of  pleurisy  following  gouty 
symptoms.  The  main  duct  of  the  organ  was  dilated  and  contained 
a  calculus  of  irregular  shape,  around  which  was  a  large  abscess  in 
the  head  of  the  organ.  This  abscess  pressed  upon  the  orifice  of  the 
bile-duct  sufficiently  to  produce  great  distention  of  the  gall-bladder. 

A  number  of  cases  of  cysts  of  the  pancreas  have  been  reported 
in  connection  with  a  calculus  in  the  duct  on  the  proximal  side  of  the 
cyst,  and  in  which  the  dilatation  of  the  duct  was  attributed  to 
obstruction  due  to  the  presence  of  the  foreign  body  in  the  duct. 
Complete  stenosis  of  the  pancreatic  duct,  due  to  intrinsic  or  extrinsic 
causes,  is  always  followed  by  parenchymatous  degeneration  of  the 
glandular  tissue  on  the  peripheral  side  of  the  seat  of  obstruction, 
which  necessarily  arrests  the  physiological  function  in  that  portion  of 
the  organ;  hence  we  are  unable  to  explain  the  retention  of  the  secre- 
tion from  this  cause,  unless  impaction  of  the  calculus  takes  place 
suddenly. 

Again,  assuming  this  to  be  the  case,  we  know  that  healthy  pan- 
creatic tissue  will  remove  its  own  secretion  by  absorption  in  case  of 
sudden  stenosis  or  obstruction  of  the  duct.  We  are,  therefore,  forced 
to   attribute  the  occurrence  of  a  pancreatic  cyst  in  the  course  of 

1  The  Lancet,  Jan.  12,  1884. 


LITHIAS1S   OF  PANCREATIC  DUCTS.  395 

gradual  or  sudden  obstruction  of  the  ducts  by  a  calculus,  or  cicatricial 
or  malignant  stenosis,  to  parenchymatous  changes  in  the  peripheral 
portion  of  the  gland  rather  than  to  the  obstruction.  This  argument, 
of  course,  applies  only  to  the  so-called  retention  cyst.  Simple, 
uncomplicated  obstruction  of  the  duct  may  give  rise  to  accumulation 
of  pathological  products  which  are  under  no  circumstances  amenable 
to  removal  by  absorption. 

The  former  assertion  is  well  illustrated  by  the  specimen  referred 
to  above,  which  Mr.  Norman  Moore '  exhibited  before  the  Pathological 
Society  of  London,  which  showed  great  dilatation  of  the  common 
pancreatic  duct  throughout  its  entire  length.  Near  the  orifice  the 
duct  was  obstructed  by  a  small  calculus  of  irregular  shape.  The 
whole  gland  was  hard  and  to  the  naked  eye  showed  a  condition  of 
advanced  connective  tissue  hyperplasia.  The  papilla  in  the  duode- 
num was  enlarged  and  the  hardened  tissue  of  the  pancreas  constricted 
the  bile-duct  so  as  to  cause  complete  obstruction.  The  liver  showed 
secondary  changes  due  to  the  stasis  of  bile.  A  microscopical  exami- 
nation of  the  specimen  showed  it  to  be  a  case  of  genuine  cirrhosis  of 
the  pancreas,  only  a  small  number  of  acini  remaining  in  healthy 
condition.  In  this  case,  the  cirrhotic  change  in  the  organ  was  un- 
doubtedly produced  in  the  same  manner  as  practiced  in  the  experi- 
ments on  animals,  by  constriction  of  the  duct;  the  first  link  in  the 
chain  of  pathological  changes  being  the  mechanical  obstruction  of 
the  duct  by  the  calculus. 

I.     Symptoms  and  Diagnosis. 

A  positive  diagnosis  of  pancreatic  lithiasis  during  life  is  impos- 
sible. Calculi  and  concretions  have  been  found  at  post-mortem 
examinations  of  persons  who,  during  life,  did  not  suffer  from  any 
symptoms  indicating  the  existence  of  such  conditions.  Pain,  fatty 
stools,  hiematemesis,  diabetes,  are  symptoms  sometimes  associated 
with  this  lesion  of  the  pancreas,  but  when  present  they  point  rather  to 
the  existence  of  a  consecutive  lesion  of  the  substance  of  the  gland 
produced  by  the  calculus,  than  to  the  presence  of  the  calculus  itself. 
If  the  calculus  be  arrested  at  the  outlet  of  Wirsung's  duct,  it  may, 
at  the  same  time,  obstruct  the  outlet  of  the  bile  by  compressing  the 
ductus  choledochus,  and  so  cause  jaundice.     But  the  same  effect 

1  Op.  cit. 


396  EXPERIMENTAL  SURGERY. 

can  also  be  produced  by  cirrhosis  of  the  head  of  the  pancreas,  with 
or  without  the  presence  of  a  calculus  in  the  pancreatic  duct. 

Mr.  Morris  claims  that  he  has  seen  cases  of  pancreatic  stone 
colic,  but  in  such  cases  it  would  be  impossible  to  differentiate  be- 
tween the  passage  of  a  biliary  and  a  pancreatic  calculus  along  their 
respective  ducts,  as  a  biliary  calculus  may  obstruct  the  common  pan- 
creatic duct  and  vice  versa. 

2.     Treatment. 

As  the  diagnosis  of  a  calculus  of  the  pancreas,  intra  vitam,  is 
impossible,  the  surgical  treatment  must  be  limited  to  the  manage- 
ment of  some  of  its  consecutive  lesions — cysts,  abscess,  and  retention 
of  bile. 

The  treatment  of  cystic  disease  and  abscess  of  the  pancreas  has 
been  considered  under  their  respective  headings,  and  I  will  only  add 
that  when  these  conditions  have  been  caused  by  an  impacted  calculus, 
an  effort  should  be  made  to  recognize  the  primary  cause  and,  if 
possible,  to  remove  it.  As  the  surgical  treatment  of  retention  of  bile 
due  to  the  mechanical  obstruction  of  the  biliary  passages  is  now 
receiving  much  attention  on  the  part  of  surgeons,  it  is  well,  in  this 
connection,  to  call  attention  to  impaction  of  a  pancreatic  calculus  in 
the  duodenal  portion  of  the  pancreatic  duct,  as  an  occasional  cause  of 
obstinate  jaundice. 

If,  in  a  case  of  this  kind,  abdominal  section  should  reveal  the 
true  nature  of  the  obstruction,  an  effort  should  be  made  at  the  time 
to  force  the  calculus  into  the  duodenum  by  taxis,  and  if  this  cannot 
be  accomplished,  the  propriety  of  cutting  for  the  stone  should  be 
carefully  considered.  As  an  impacted  calculus  in  this  locality  not 
only  endangers  the  life  of  the  patient  by  cholaemia,#but  may  also 
destroy  life  suddenly  by  perforation  into  the  peritoneal  cavity,  it 
would  be  not  only  justifiable  but  good  treatment  to  remove  it  after  a 
positive  diagnosis  has  been  made  by  means  of  diagnostitial  lapar- 
otomy. The  greatest  danger  attending  such  a  procedure  would  be 
extravasation  of  bile  into  the  peritoneal  cavity.  This  accident 
should  be  guarded  against  by  removing  the  retained  bile  by  aspira- 
tion of  the  dilated  bile-ducts,  as  a  preliminary  measure.  After  extrac- 
tion of  the  stone  the  incision  in  the  duct  should  be  accurately  closed 
with  fine  silk  sutures.     The  secretion  of  bile  and  pancreatic  juice 


CONCLUSIONS.  397 

should  be  reduced  to  a  minimum  after  the  operation  by  keeping  the 
digestive  organs  in  a  condition  of  absolute  physiological  rest  during 
the  time  required  for  the  healing  of  the  visceral  wound. 

XVI.     Conclusions. 

1.  Restoration  of  the  continuity  of  the  pancreatic  duct  does  not 
take  place  after  complete  section  of  the  pancreas. 

2.  Complete  extirpation  of  the  pancreas  is  invariably  followed 
by  death,  produced  either  by  the  traumatism  or  by  gangrene  of  the 
duodenum. 

3.  Partial  excision  of  the  pancreas  for  injury  or  disease  is  a 
feasible  and  justifiable  surgical  procedure. 

4.  Complete  obstruction  of  the  pancreatic  duct,  uncomplicated 
by  pathological  conditions  of  the  parenchyma  of  the  organ,  never 
results  in  the  formation  of  a  cyst. 

5.  In  simple  obstruction  of  the  pancreatic  duct,  the  pancreatic 
juice  is  removed  by  absorption. 

6.  Gradual  atrophy  of  the  pancreas  from  nutritive  or  degener- 
ative changes  of  the  secreting  structure  is  not  incompatible  with 
health. 

7.  Physiological  detachment  of  any  portion  of  the  pancreas  is 
invariably  followed  by  progressive  degeneration  and  atrophy  of  the 
glandular  tissue. 

8.  Extravasation  of  fresh  normal  pancreatic  juice  into  the  peri- 
toneal cavity  does  not  produce  peritonitis,  but  the  juice  is  promptly 
removed  by  absorption. 

9.  Crushed  or  lacerated  pancreatic  tissue  is  removed  by  absorp- 
tion, provided  the  site  of  operation  remains  aseptic. 

10.  Complete  division  of  the  pancreas  by  elastic  constriction  is 
never  followed  by  restoration  of  interrupted  anatomical  continuities. 

11.  Limited  detachment  of  the  mesentery  from  the  duodenum, 
as  required  in  operations  upon  the  pancreas,  is  not  followed  by  gan- 
grene of  the  bowel. 

12.  In  all  operations  upon  the  head  of  the  pancreas,  the  phy- 
siological connection  of  the  peripheral  portion  of  the  gland  should  be 
maintained  by  preserving  the  integrity  of  the  main  pancreatic  duct. 


398  EXPERIMENTAL  SURGERY. 

13.  Partial  excision  of  the  splenic  portion  of  the  pancreas  is 
indicated  in  cases  of  circumscribed  abscess  and  malignant  tumors,  in 
all  cases  where  the  pathological  product  can  be  removed  completely 
without  danger  of  compromising  pancreatic  digestion  or  inflicting 
additional  injury  upon  important  adjacent  organs. 

14.  Ligation  of  the  pancreas  at  the  point  or  points  of  section 
should  precede  extirpation  as  a  prophylactic  measure  against 
troublesome  haemorrhage  and  extravasation  of  pancreatic  juice  into 
the  peritoneal  cavity. 

15.  The  formation  of  an  external  pancreatic  fistula  by  abdomi- 
nal section  is  indicated  in  the  treatment  of  cysts,  abscesses,  gangrene, 
and  haemorrhage  of  the  pancreas  due  to  local  causes. 

16.  Abdominal  section  and  lumbar  drainage  are  indicated  in 
cases  of  abscess  or  gangrene  of  the  pancreas  where  it  is  found 
impossible  to  establish  an  anterior  abdominal  fistula. 

17.  Through  drainage  is  indicated  in  cases  of  abscess  and 
gangrene  of  the  pancreas,  with  diffuse  burrowing  of  pus  in  the 
retroperitoneal  space. 

18.  Removal  of  an  impacted  pancreatic  calculus  in  the  duode- 
nal extremity  of  the  duct  of  Wirsung,  by  taxis,  or  incision  and 
extraction,  should  be  practiced  in  all  cases  where  the  common  bile- 
duct  is  compressed  or  obstructed  by  the  calculus,  and  where  death 
is  threatened  by  cholsemia. 

19.  In  such  cases  the  principal  source  of  danger,  extravasation 
of  bile  into  the  peritoneal  cavity,  should  be  avoided  by  preliminary 
aspiration  of  the  dilated  bile-ducts,  accurate  closure  of  the  visceral 
wound  with  fine  silk  sutures,  and  absolute  physiological  rest  of  the 
organs  of  digestion  during  the  time  required  for  the  healing  of 
the  visceral  wound. 


AN    EXPERIMENTAL    CONTRIBUTION     TO     INTES- 
TINAL SURGERY  WITH  SPECIAL  REFER- 
ENCE    TO     THE     TREATMENT     OF 
INTESTINAL  OBSTRUCTION.1 


The  most  important,  and,  at  the  same  time,  the  most  popular 
topic  for  discussion  among  surgeons  of  the  present  day  is  intestinal 
surgery.  The  current  medical  literature  is  teeming  with  reports  of 
cases,  and  at  the  meetings  of  almost  every  medical  and  surgical  soci- 
ety, large  or  small,  this  subject  comes  up  for  discussion  and  occupies 
a  liberal  space  and  conspicuous  place  in  their  printed  transactions. 
The  unusual  activity  which  has  been  manifested  in  all  parts  of  the 
civilized  world  in  the  development  of  this,  one  of  the  most  modern 
and  aggressive  departments  of  abdominal  surgery,  is  sufficient 
evidence  that  the  subject  is  comparatively  new,  and  as  yet  imper- 
fectly understood.  A  study  of  the  literature  of  intestinal  surgery 
must  convince  every  unprejudiced  mind  that  here,  as  in  many  other 
difficult  problems  in  surgeiy,  the  positive  knowledge  which  we  have 
acquired  rests  almost  exclusively  on  the  results  obtained  by  experi- 
mental research.  Gunshot  wounds  of  the  abdominal  cavity  have 
been  made  the  object  of  careful  and  patient  experimentation  by  a 
number  of  enthusiastic  surgeons,  and  the  results  obtained  have  laid 
the  foundation  for  a  rational  method  of  treatment  of  these  injuries, 
which  has  been  eagerly  accepted  by  all  modern  aggressive  and  pro- 
gressive surgeons.  The  practical  results  which  have  been  obtained 
thus  far  in  the  hands  of  a  number  of  surgeons  have  been  the  means 
of  saving  a  number  of  lives,  which  by  the  old  conservative  method  of 
treatment  would  have  been  doomed  to  inevitable  death  from  hsemor 
rhage  or  septic  peritonitis.  The  numerous  valuable  practical  sugges- 
tions for  treatment  of  gunshot  injuries  of  the  intestines  are  the 
direct   outcome   of  experiments  on  animals,   and  this,   as   well    as 

1  Read  in  the  Surgical  Section  of  the  Ninth  International  Medical  Congress, 
Washington,  September  5,  1887. 

399 


400  EXPERIMENTAL  SURGERY. 

the  remarkable  recoveries  following  gunshot  wounds  of  the  abdomen 
treated  by  laparotomy,  have  so  firmly  convinced  the  profession  of 
the  necessity  of  resorting  to  operative  measures  in  such  cases,  that 
few  surgeons  could  be  found  at  the  present  day  who  would  be  willing 
to  trust  to  conservative  treatment  any  case  where  positive,  or  only 
probable,  evidences  pointed  towards  the  existence  of  a  visceral  injury 
of  any  portion  of  the  intestine. 

While  a  decided  advance  has  been  made  in  the  treatment  of 
injuries  of  the  intestinal  tract,  the  operative  treatment  of  intestinal 
obstruction  still  constitutes  one  of  the  darkest  and  most  unsatisfactory 
chapters  in  the  wide  domain  of  intestinal  surgery.  The  obscurity 
and  uncertainty  which  cling  to  this  subject  are  due  to  the  difficulties 
which  often  surround  an  accurate  diagnosis.  At  the  same  time  we 
have  every  reason  to  believe  that  the  appalling  mortality  which  has 
so  far  attended  the  surgical  treatment  of  intestinal  obstruction  is 
mainly  due  to  late  operations,  and  not  infrequently  to  a  faulty 
technique  in  the  removal  of  the  cause  of  the  obstruction,  and  in 
the  restoration  of  the  continuity  of  the  intestinal  canal.  An  accurate 
anatomical  or  pathological  diagnosis  in  such  cases  during  life  is  often 
difficult,  if  not  impossible,  and  when,  as  a  dernier  ressort,  laparot- 
omy is  performed,  and  the  surgeon  is  confronted  by  an  unexpected 
condition  of  things,  he  is  often  in  doubt  as  to  what  course  to  pursue, 
and  frequently  ends  the  operation  by  establishing  an  artificial  anus. 
No  one  who  has  been  forced  to  resort  to  this  measure  has  left  his 
patient  with  a  feeling  of  satisfaction,  as  he  must  have  been  sadly 
impressed  with  the  fact,  that,  at  best,  he  has  only  been  instrumental 
in  relieving  the  urgent  symptoms  of  the  obstruction,  while  he  has 
failed  to  remove  its  cause,  and  consequently  also  in  restoring  the 
continuity  of  the  intestinal  canal.  A  patient  with  an  artificial  anus 
is  indeed  an  object  of  commiseration,  as  experience  has  sufficiently 
demonstrated  how  difficult  it  is  in  many  instances  to  close  the  abnor- 
mal outlet,  even  after  the  cause  of  obstruction  is  subsequently 
removed  or  corrected  spontaneously,  without  exposing  him  a  second 
time  to  the  risks  of  life  incident  to  another  abdominal  section.  If 
the  causes  which  have  led  to  the  obstruction  are  of  a  permanent 
character,  all  attempts  at  closing  the  fistulous  opening  will,  of  course, 
prove  worse  than  useless,  and  the  patient  is  condemned  to  suffer  from 
this  loathsome  condition  the  balance  of  his  or  her  lifetime,  without  a 
hope  of  ultimate  relief.     I  believe  I  can  safely  make  the  statement 


TREATMENT    OF  INTESTINAL    OBSTRUCTION  401 

without  foar  of  contradiction  that  most  of  these  unfortunate  patients 
would  prefer  death  itself  to  such  a  life  of  misery.  The  ideal  of  an 
operation  for  intestinal  obstruction  embraces  the  fulfillment  of  two 
principal  indications : 

1.  The  removal  or  rendering  harmless  of  the  cause  of  obstruc- 
tion. 

2.  The  immediate  restoration  of  the  continuity  of  the  intestinal 
canal. 

To  meet  the  first  indication  the  cause  of  obstruction  must  be 
found,  its  nature  determined,  and  whenever  advisable  or  practicable, 
it  is  removed,  a  step  in  the  operation  which  may  be  very  easy,  or 
may  demand  a  most  formidable  and  serious  undertaking,  more 
especially  in  cases  where  the  pathological  conditions  which  have 
given  rise  to  the  obstruction  are  of  such  a  nature  as  to  constitute  in 
themselves  an  imminent  or  remote  source  of  danger,  as,  for  instance, 
malignant  disease  or  gangrene  of  the  bowel  from  constriction.  In 
all  cases  of  inoperable  conditions  the  cause  of  obstruction  is  rendered 
harmless  as  far  as  obstruction  is  concerned  by  establishing  an 
anastomosis  between  the  bowel  above  and  below  the  obstruction  by 
an  operation  which  will  be  described  further  on. 

Immediate  restoration  of  the  continuity  of  the  intestinal  canal 
should  be  secured  in  the  operative  treatment  of  all  cases  of  intesti- 
nal obstruction,  with  the  exception  of  inoperable  cases  of  carcinoma 
of  the  rectum,  but  is  most  urgently  indicated  in  cases  of  obstruction 
in  the  upper  portion  of  the  small  intestines  and  the  colon,  as  the 
formation  of  an  artificial  anus  in  the  former  locality  would  prove 
a  direct  source  of  danger  from  marasmus,  by  excluding  too  large  a 
surface  for  intestinal  digestion  and  absorption,,  while  in  the  latter 
situation  the  cure  of  a  faecal  fistula  only  too  often  proves  an  oppro- 
brium of  surgery.  A  careful  perusal  of  the  literature  on  the 
treatment  of  intestinal  obstruction  proves  only  too  plainly  the  im- 
perfection of  this  branch  of  surgery.  The  rules  laid  down  in  our 
text-books  are*  often  given  with  so  much  hesitation  that  it  becomes 
impossible  to  apply  them  in  practice.  Opinions  are  so  widely  at 
variance  that  every  surgeon  finally  acts  upon  the  impulse  of  the 
moment  and  adopts  a  method  which  ho  deems  appropriate  for  his 
case.  It  can  be  said  that  no  uniformity  of  action  exists,  consequently 
the  statistics  which  have  been  produced  so  fur  arc  of  but,  little  value 
from   a   practical   standpoint.     A   rational   and  successful  surgical 


402  EXPERIMENTAL  SURGERY. 

treatment  of  intestinal  obstruction,  like  other  abdominal  operations, 
can  only  be  established  upon  a  basis  founded  upon  the  results 
obtained  by  experimental  investigation.  In  view  of  this  fact  it  is 
astonishing  that  so  little  has  been  accomplished  in  this  direction.  I 
am  convinced  that  accurate  work  of  this  kind  will  render  essential 
information  in  the  diagnosis  of  the  obscure  causes  of  obstruction, 
and  will  point  out  more  clearly  the  indications  for  operative  inter- 
ference, while  improved  methods  of  operation  will  have  to  be  studied 
exclusively  in  this  manner. 

Durincr  the  last  eighteen  months  I  have  made  one  hundred  and 
fifty  operations  on  animals  for  the  purpose  of  studying  the  effects 
of  the  principal  varieties  of  intestinal  obstruction,  which  were  pro- 
duced artificially ;  at  the  same  time  I  have  attempted  to  establish 
a  number  of  new  operations  for  the  relief  of  certain  forms  of  intes- 
tinal obstruction  where  it  is  impossible  or  inadvisable  to  remove  the 
local  conditions  which  gave  rise  to  the  obstruction.  One  of  the 
greatest  dangers  in  all  operations  for  intestinal  obstruction  is  the 
length  of  time  required  to  perform  the  ordinary  operations ;  hence 
it  has  been  my  object  to  simplify  the  operations,  and  thus  by  short- 
ening the  time  diminish  the  danger  from  shock.  All  patients 
requiring  an  operation  for  intestinal  obstruction  are  invariably  in 
a  condition  not  well  adapted  for  prolonged  operations,  which  neces- 
sitate the  opening  of  the  peritoneal  cavity  and  exposure  of  its 
contents  to  the  cooling  influences  of  the  atmospheric  air.  An  opera- 
tion which  can  be  completed  in  twenty  minutes  must  certainly  prove 
less  disastrous  to  the  patient  than  one  requiring  from  one  to  two 
hours.  A  prolonged  operation  on  the  intestines  is  attended  by  two 
great  risks  :  1.  Immediate,  due  to  shock.  2.  Remote,  prolonged 
exposure  to  infection.  Both  of  these  dangers  are  diminished  in 
proportion  to  the  shortening  of  the  time  consumed  in  the  operation, 
which  is  made  possible  by  resorting  to  simpler  measures,  provided 
they  are  equally  safe  and  efficient. 

General  Remarks  on  Experiments. 

With  few  exceptions  the  experiments  detailed  in  this  paper 
were  made  at  the  Milwaukee  County  Hospital,  located  at  Wauwatosa, 
six  miles  from  Milwaukee;  and  here  I  desire  to  return  my  thanks 
to  Dr.  M.  E.  Connel,  superintendent  of  the  hospital,  and  his 
assistants,   as   well   as   to  Dr.  William  Mackie,  of  Milwaukee,  for 


REMARKS   ON  EXPERIMENTS.  403 

valuable  services  rendered  in  my  experimental  work.  As  the  main 
object  of  these  experiments  was  not  to  show  favorable  statistics,  but 
more  for  the  purpose  of  studying  the  effect  of  different  forms  of 
intestinal  obstruction  and  to  establish  new  principles  of  treatment, 
the  animals  were  not  submitted  to  any  special  treatment  before  or 
after  the  operation;  the  diet  was  not  restricted  and  no  internal 
medicines  were  given.  I  pursued  this  course  in  order  to  bring  the 
intestinal  canal  in  the  most  unfavorable  conditions  for  operative 
interference,  so  as  to  expose  the  operations  to  the  severest  test. 
Ether  was  used  exclusively  as  an  anaesthetic.  The  abdomen  was 
shaved,  thoroughly  washed  with  soap  and  warm  water,  and  disin- 
fected with  a  1-1000  solution  of  corrosive  sublimate  or  a  two  and  a 
half  per  cent,  solution  of  carbolic  acid.  For  the  sponges  the  same 
solution  of  carbolic  acid  or  a  weaker  solution  of  corrosive  sublimate 
was  used.  The  abdomen  was  covered  by  several  layers  of  aseptic 
gauze,  with  a  slit  in  the  centre. 

Whenever  division  or  incision  of  the  bowel  was  made,  fsecal 
extravasation  was  guarded  against  by  compressing  the  bowel  on  each 
side  by  compressors  made  for  this  special  purpose,  or  by  constriction 
with  an  elastic  rubber  band.  Experience  showed  that  the  latter 
method  was  preferable,  as  it  proved  less  injurious  to  the  tissues  of 
the  bowel,  and  afforded  greater  security  against  extravasation,  while 
at  the  same  time  it  proved  less  disastrous  to  the  circulation  between 
the  points  of  compression.  The  rubber  bands  for  this  purpose  should 
be  about  an  eighth  of  an  inch  in  width,  rendered  properly  aseptic  by 
prolonged  immersion  in  a  five  per  cent,  solution  of  carbolic  acid,  and 
can  be  readily  applied  by  perforating  the  mesentery  with  an  ordinary 
haemostatic  forceps  at  a  point  not  supplied  with  visible  blood  vessels, 
and  tied  in  a  loop  with  sufficient  firmness  to  obstruct  the  lumen  of 
the  bowel.  Elastic  constriction  practiced  in  this  manner  prevents  all 
possibility  of  extravasation,  and  does  not  interfere  with  the  free 
manipulations  of  the  operator,  as  is  the  case  with  clamps  or  the 
hands  of  an  assistant,  while  the  degree  of  compression  that  is 
necessary  exerts  no  injurious  effects  on  the  vessels  and  tissues  at 
the  seat  of  constriction.  Drainage  was  never  resorted  to,  and  the 
abdominal  wound  was  always  closed  by  deep  interrupted  sutures 
including  the  peritoneum.  In  all  cases  where  partial  or  complete 
exventration  was  made  necessary,  the  bowels  were  kept  covered  with 
warm  gauze  compresses.     In  all  cases  where  complete  exventration 


404  EXPERIMENTAL   SURGERY. 

became  necessary,  and  where  the  bowels  remained  out  of  the 
abdomen  for  half  an  honr  or  more,  a  certain  degree  of  shock  was 
always  noticed,  and  a  number  of  animals  died  within  a  few  hours 
after  the  operation,  death  being  referable  directly  to  this  cause.  For 
an  external  dressing  we  used  iodoform  ointment  applied  directly 
over  the  wound,  and  a  compress  of  cotton,  retained  by  a  bandage, 
and  a  jacket  made  of  coarse  cloth.  As  a  rule  the  sutures  were 
removed  at  the  end  of  six  days,  when  the  wound  was  usually  found 
healed  by  primary  union. 

I.    Artificial  Intestinal  Obstruction. 

In  imitation  of  the  more  common  forms  of  intestinal  obstruction 
in  the  human  subject,  due  to  congenital  malformation  or  pathologi- 
cal conditions,  the  following  kinds  of  obstruction  were  produced  on 
animals:  (1)  stenosis,  (2)  flexion,  (3)  volvulus,  (4)  invagination.  It 
is  a  noteworthy  fact  that  even  in  cases  where  the  obstruction  was 
complete  from  the  beginning,  vomiting  was  moderate,  and  in  some 
instances  entirely  absent.  As  vomiting  constitutes  one  of  the  earliest 
and  most  conspicuous  and  persistent  symptoms  in  most  cases  of 
intestinal  obstruction  in  man,  we  can  only  explain  its  lesser  intensity 
or  complete  absence  in  animals  from  the  circumstance  that  animals 
suffering  from  this  condition,  as  a  rule,  refuse  all  food  and  drink. 
As  a  rule,  the  tympanitis  was  also  less  marked  than  in  the  human 
subject. 

I.    Stenosis. 

Circular  narrowing  of  the  lumen  of  the  bowel  was  produced  by 
excision  of  a  semi-lunar  piece  of  the  intestinal  wall  and  double 
suturing  of  the  wound  in  a  direction  parallel  to  the  intestine;  and  by 
circular  constriction  with  bands  of  aseptic  gauze. 

a.    Partial  Enterectomy. 

Experiment  1.  Dog,  weight  thirty-nine  pounds.  A.  semi-lunar  portion 
embracing  half  the  circumference  of  the  bowel  removed  from  the  convex 
surface,  two  inches  above  the  ileo-csecal  valve.  Wound  closed  in  a  longitudinal 
direction  by  Czerny-Lembert  suture.  The  first  two  weeks  the  discharges 
from  the  bowels  were  fluid  and  dark  in  color,  subsequently  normal  in  color  and 
consistence.  Animal  killed  thirty-six  days  after  operation.  Body  well  nour- 
ished; abdominal  wound  indicated  by  a  firm  linear  cicatrix.  Omentum 
adherent  at  point  of  operation;  lumen  of  bowel  at  point  of  operation  reduced 
one-half  in  size;  lumen  of  bowel  above  and  below  the  contraction  equal  in  size, 
showing  that  the  stenosis  had  not  furnished  an  obstacle  to  the  passage  of 


STENOSIS.  4<  )5 

intestinal  contents.     A  few  of  the  sntnres  remained  attached,  their  free  ends 
floating  in  the  bowel. 

Experiment  2.  Large,  full-grown  cat.  The  same  operation  was  performed 
on  the  concave  side  of  the  bowel  about  the  middle  of  the  ileum,  a  semi-lunar 
piece  of  the  wall  of  the  intestine  with  the  corresponding  mesentery  being 
removed  and  the  wound  closed  in  a  similar  manner,  which  diminished  the 
diameter  of  the  lumen  of  the  bowel  to  about  one-eighth  of  an  inch.  It  was 
noticed  during  the  operation  that  the  convex  surface  of  the  bowel  over  an 
area  corresponding  to  the  partial  excision  presented  a  cyanosed  appearance. 
The  animal  died  on  the  fourth  day  after  operation,  and  the  whole  segment  of 
the  sutured  bowel  was  found  gangrenous,  but  no  fluid  in  the  abdominal 
cavity. 

Experiment  3.  Large,  adult  cat.  In  this  case  a  segment  of  the  ileum  was 
emptied  of  its  contents,  and  before  cutting  away  a  semi -lunar  piece  from  the 
convex  surface,  a  back-stitch,  continuous  suture  was  applied  on  the  inner 
margin  of  the  proposed  line  of  incision,  which  left  about  one-third  of 
the  lumen  of  the  bowel.  After  excision  of  the  semi-lunar  piece  the  margins 
of  the  cut  surface  were  turned  inwards  and  covered  with  serous  surface  by  a 
continuous  catgut  suture.  Several  small  passages  occurred  after  the  operation, 
but  the  animal  died  on  the  fourth  day  with  symptoms  of  intestinal  obstruction. 
The  visceral  wound  was  found  healed,  but  the  lumen  had  become  so  narrow 
from  the  inflammatory  swelling  of  the  tunics  of  the  bowel  that  it  was  entirely 
inadequate  for  the  passage  of  intestinal  contents,  and  as  a  result  of  this 
obstruction  the  bowel  had  become  considerably  dilated  above  the  point 
of  operation. 

Remarks. — These  experiments  illustrate  conclusively  that  in 
wounds  of  the  convex  side  of  the  intestine,  where  from  the  nature  of 
the  injury  transverse  suturing  is  impossible,  longitudinal  approxima- 
tion and  suturing  can  be  safely  done,  provided  at  least  one-half  of 
the  lumen  of  the  bowel  can  be  preserved.  If  the  stenosis  is  carried 
beyond  this  point  there  is  great  danger  that  the  inflammatory  swell- 
ing following  the  operation  will  still  further  narrow  the  tube  and 
lead  to  the  most  serious  consequences  due  to  intestinal  obstruction, 
and  place  the  visceral  wound  in  the  most  unfavorable  condition  for 
the  healing  process. 

Experiment  No.  2  shows  the  great  danger  of  interference  with 
the  blood  supply  from  the  mesentery  in  longitudinal  suturing  of 
wounds  on  the  concave  side  of  the  bowel,  as  such  a  procedure  is 
invariably  followed  by  gangrene  of  the  corresponding  segment  of 
bowel  on  the  convex  side. 

b.    Circular  Constriction. 
The  following  experiments  were  made  to  study  tho  effect  of 
circular  constriction  upon  the  circulation  of  the  isolated  constricted 


406  EXPERIMENTAL  SURGERY. 

loop  of  bowel.  In  all  cases  where  the  constriction  was  made  with  a 
gauze  band,  this  was  tied  with  the  same  degree  of  firmness,  so  as  to 
determine  whether  the  same  degree  of  strangulation  would  produce 
identical  results. 

Experiment  4.  Adult  cat.  A  loop  of  bowel  about  the  middle  of  the 
ileum,  six  inches  in  length,  was  tied  with  a  band  of  aseptic  gauze  with  suffi- 
cient firmness  to  cause  slight  congestion,  but  without  interfering  with  a  free 
arterial  supply,  as  the  arteries  in  the  ligated  portion  continued  to  pulsate 
freely.  The  day  after  operation  a  few  small  fgecal  discharges  stained  with 
blood.  The  cat  died  forty-eight  hours  after  the  operation.  No  rise  in  temper- 
ature was  observed,  and  death  was  evidently  caused  by  collapse  from  perfora- 
tion. The  loop  of  bowel  showed  gangrene  on  convex  side  equidistant  from 
the  point  of  strangulation,  and  a  small  perforation  which  had  given  rise  to 
diffuse  septic  peritonitis.  The  whole  visceral  and  parietal  peritoneum  was 
uniformly  affected  and  the  peritoneal  cavity  contained  a  considerable  quan- 
tity of  sero-sanguinolent  fluid. 

Experiment  5.  Large,  adult  cat.  A  loop  of  the  ileum  of  the  same  length 
was  tied  in  a  similar  manner  and  with  same  degree  of  firmness.  The  animal 
absolutely  refused  food  until  the  eighth  day.  Rise  in  temperature  second  and 
third  day.  Only  one  fsecal  discharge  on  the  second  day.  Killed  eight  days 
after  operation.  Abdominal  wound  completely  united;  no  peritonitis.  Four 
inches  of  bowel  below  the  point  of  constriction  showed  that  partial  reduc- 
tion had  taken  place.  The  gauze  band  was  found  completely  covered  with 
adherent  omentum,  and  a  thick  layer  of  plastic  lymph  which  formed  a  com- 
plete bridge  connecting  the  intestine  above  and  below  the  ligature.  The 
ligated  portion  showed  no  evidence  of  defective  circulation,  and  no  ulceration 
underneath  the  ligature.  The  obstruction  was  complete,  as  no  fluid  could  be 
forced  through  the  bowel,  and  in  proof  that  the  same  condition  existed  during 
life,  it  was  found  that  the  bowel  above  the  constriction  was  considerably 
dilated,  while  below  the  strangulation  it  was  empty  and  contracted. 

Experiment  6.  Large,  Maltese  cat.  A  loop  of  the  ileum,  six  inches  in 
length,  tied  in  a  similar  manner.  On  the  third  day  faeces  stained  with  blood. 
On  the  same  day  the  temperature,  which  had  remained  nearly  normal  until 
this  time,  rose  to  105°  F.,  and  on  the  following  day  the  animal  died,  having 
manifested  symptoms  of  perforative  peritonitis  for  twenty-four  hours. 
Abdominal  wound  united;  recent  diffuse  peritonitis.  The  abdominal  cavity 
contained  several  ounces  of  sero-purulent  fluid.  Bowel  above  constriction 
distended  with  fluid  contents,  below  the  obstruction  empty  and  slightly  con- 
tracted. The  greater  portion  of  strangulated  loop  was  found  gangrenous  and 
adherent  to  adjacent  loops  of  bowel.  Perforation  had  taken  place  in  the 
middle  of  the  loop  on  the  convex  surface,  showing  that  gangrene  had  taken 
place  first  at  this  point  and  had  extended  from  here  towards  the  ligature. 

Experiment  7.  Adult  dog,  weight  twenty-six  pounds.  In  this  case  an 
opening  was  made  in  the  mesentery  through  which  a  loop  of  the  small  intes- 
tine, six  inches  in  length,  was  pushed.     With  sutures  this  opening  was  made 


FLEXION.  407 

sufficiently  small  so  that  its  margins  produced  slight  strangulation.  The  dog 
remained  perfectly  well  after  the  operation,  and  was  killed  on  the  twenty- 
second  day.  Abdominal  wound  completely  healed.  No  signs  of  peritonitis. 
On  searching  fcr  the  seat  of  obstruction  it  was  found  that  spontaneous  reduc- 
tion had  taken  place,  the  site  of  perforation  in  the  mesentery  being  indicated 
by  a  recent  cicatrix. 

Remarks. — The  post  mortem  appearances  in  these  cases  demon- 
strate clearly  that  the  gangrene  was  not  produced  by  the  primary 
mechanical  strangulation,  but  that  it  depended  upon  consecutive 
pathological  changes  in  the  loop  or  its  vessels.  In  experiment  No.  5 
the  primary  strangulation  was  fully  as  great  as  in  the  preceding 
experiment,  and  yet  gangrene  did  not  take  place,  and  we  have  posi- 
tive proof  that  vascular  engorgement  in  the  ligated  portion  was  less 
intense  from  the  fact  that  partial  reduction  took  place.  In  all  cases 
where  gangrene  resulted,  it  must  not  have  been  from  deficient  arte- 
rial blood  supply,  but  from  an  obstruction  to  the  return  of  blood 
through  the  veins.  If  defective  arterial  blood  supply  had  been 
the  immediate  cause  of  the  gangrene,  we  would  have  found  more 
constantly  gangrene  of  the  entire  loop,  while  every  specimen  illus- 
trated that  gangrene  always  commenced  at  a  point  where  the  return 
of  venous  blood  met  with  the  greatest  resistance,  viz.,  on  the  convex 
surface  in  the  middle  portion  of  the  loop.  As  in  cases  of  hernia, 
or  in  any  other  form  of  intestinal  strangulation,  where  a  firm  con- 
stricting band  surrounds  the  loop  of  bowel,  the  danger  of  complete 
strangulation  is  increased  if  by  the  peristaltic  action  additional 
portions  of  the  intestine  are  forced  through  the  ring;  and  the  imme- 
diate cause  of  the  gangrene  is  always  referable  to  obstruction  to  the 
return  of  venous  blood,  which  leads  rapidly  to  cedema,  complete 
stasis,  and  moist  gangrene  in  that  portion  where  the  venous  circula- 
tion is  most  seriously  impaired.  Violent  peristalsis  under  such 
circumstances  always  aggravates  the  existing  conditions,  and  is  often 
the  precursor  of  symptoms  of  complete  strangulation.  In  such 
cases  opiates  act  favorably  by  arresting  peristaltic  action,  and  in  so 
doing  may  avert  gangrene  by  preventing  the  causes  which  otherwise 
would  have  led  to  complete  venous  stasis. 

2.     Flexion. 

As  many  instances  are  on  record  where  flexion  of  the  bowel 
constituted  the  cause  of  intestinal  obstruction,  this  condition  was 
artificially  produced  in  animals  either  by  making  a  partial  entorec- 


408  EXPERIMENTAL  SURGERY. 

tomy  by  removing  a  wedge-shaped  piece  from  one  side  of  the  bowel, 
or  by  bending  the  bowel  upon  itself  acutely,  and  fixing  it  in  this 
position  with  catgut  sutures. 

Experiment  8.  Dog,  weight  sixty  pounds.  A  wedge-shaped  piece  of  the 
wall  of  the  ileum  was  removed  from  the  concave  side  with  a  corresponding 
portion  of  the  mesenteric  attachment,  and  after  arresting  the  bleeding  by 
tying  several  vessels  with  catgut,  the  wound  was  closed  transversely  by  two 
rows  of  sutures.  The  excised  piece  measured  one  inch  at  its  base,  and  the 
apex  reached  as  far  as  the  median  line  of  the  bowel.  Immediately  after 
excision,  the  convex  portion  of  the  bowel  which  had  become  acutely  flexed  by 
uniting  the  wound,  presented  a  livid,  congested  appearance,  and  after  tying 
the  sutures  the  cyanosis  increased.  The  area  of  disturbance  of  the  circulation 
corresponded  to  the  width  of  the  base  of  the  excised  portion.  About  fourteen 
inches  from  this  place  a  similar  piece  was  excised  from  the  convex  side  of  the 
bowel,  and  the  wound  closed  in  the  same  manner.  At  this  point  the  flexion 
was  only  slight,  the  mesenteric  portion  forming  the  prominence  of  the  curve. 
On  the  third  day  the  temperature  rose  to  105.6°  F.,  and  the  following  day  the 
animal  died  with  symptoms  indicative  of  perforative  peritonitis.  On  opening 
the  abdomen,  diffuse  general  peritonitis  was  found  with  numerous  adhesions. 
Gangrene  and  perforation  were  found  on  the  convex  side  directly  opposite  the 
place  of  first  operation.  Second  visceral  wound  closed,  and  lumen  of  bowel 
at  this  point  somewhat  contracted,  but  permeable  to  fluids. 

Experiment  9.  Large,  adult  cat.  Removed  from  convex  side  of  ileum  a 
triangular  piece  measuring  one  inch  at  its  base,  the  apex  reaching  a  little 
beyond  the  middle  line  of  the  bowel.  Wound  closed  transversely  by  Czerny- 
Lembert  sutures.  After  closure  of  the  wound  the  bowel  presented  at  point  of 
partial  resection  an  obtuse  angle,  the  apex  being  formed  by  the  mesenteric 
portion.  The  stools  were  bloody  the  second  day  after  operation.  The  animal 
remained  in  excellent  condition  until  it  was  killed,  forty-three  days  after 
operation.  Adhesions  of  loops  of  small  intestines  to  abdominal  wound,  and 
of  omentum  and  adjacent  intestines  at  point  of  operation.  The  extent  of 
flexion  was  found  somewhat  diminished,  yet  the  concavity  on  convex  side 
of  bowel  was  well  marked.  Size  of  bowel  above  and  below  the  operation  was 
equal,  showing  that  the  flexion  had  not  acted  as  a  cause  of  obstruction.  On 
opening  the  bowel  a  pouch-like  bulging  was  found  on  the  mesenteric  side, 
which  appeared  to  compensate  for  the  narrowing  caused  by  the  artificial 
stenosis.  Two  of  the  deep  sutures  still  remained  attached  to  the  inner  surface 
of  the  bowel. 

Experiment  10.  Large,  adult  cat.  In  this  case  a  loop  of  the  middle  por- 
tion of  the  ileum,  four  inches  in  length,  was  acutely  flexed  in  such  a  manner 
that  the  peritoneal  surfaces  of  the  convex  side  were  brought  in  contact,  and 
in  this  position  the  bowel  was  fixed  by  a  number  of  fine  catgut  sutures.  No 
symptoms  pointing  towards  intestinal  obstruction  were  observed,  and  the 
animal  was  killed  sixteen  days  after  the  operation.  Wound  was  found  com- 
pletely united,  and  no  signs  of  peritonitis.  The  angle  of  flexion  had  some- 
what diminished,  but  otherwise  the  bowel  was  adherent  in  position  left  after 


VOLVULUS.  409 

operation.  The  bowel  presented  no  dilatation  above  nor  contraction  below  the 
flexion,  showing  that  complete  permeability  of  the  canal  at  the  point  of 
flexion  was  quickly  restored. 

Remarks. — The  partial  excision  on  concave  side  of  bowel  in 
experiment  No.  8,  illustrates  the  danger  of  suturing  wounds  in  this 
locality"  where  the  blood  supply  from  the  mesentery  is  likewise 
impaired,  as  gangrene  of  the  remaining  portion  of  the  bowel  is 
almost  certain  to  take  place.  In  all  wounds  on  this  side  of  the 
bowel  more  than  half  an  inch  in  length,  there  is  also  another  great 
danger  which  attends  transverse  suturing,  viz.,  stenosis,  which  may 
become  the  cause  of  intestinal  obstruction.  As  the  small  intestines 
naturally  describe  quite  a  strong  curve  with  the  concavity  on  the 
mesenteric  side,  closure  of  a  wound  involving  this  portion  of  the 
bowel  gives  rise  to  acute  flexion  which,  at  least  during  the  process 
of  healing,  must  cause  more  or  less  obstruction,  until  by  yielding  of 
the  opposite  portion  of  the  intestinal  wall  an  adequate  dilatation 
of  the  calibre  of  the  tube  has  taken  place.  A  considerable  portion  of 
the  wall  on  the  convex  side  of  the  bowel  can  be  removed  and  sutured 
transversely  until  the  bowel  has  been  transformed  into  a  straight 
tube,  and  a  wound  an  inch  in  length  will  make  only  a  slight  flexion 
which  furnishes  no  serious  mechanical  obstacle  to  the  passage  of  the 
intestinal  contents.  In  this  connection  the  question  arises:  Does 
simple  flexion,  even  if  acute,  without  diminution  of  the  lumen  of  the 
bowel,  give  rise  to  symptoms  of  obstruction  ?  I  have  made  numer- 
ous flexions  when  performing  operations  for  establishing  intestinal 
anastomosis,  and  in  most  instances  satisfied  myself  by  examination 
of  the  specimens  that  fluids  passed  them  without  great  difficulty.  If 
the  bowel  at  the  point  of  flexion  remains  free,  certain  portions  of  its 
wall  will  yield  to  pressure  of  the  fluid  intestinal  contents,  and  grad- 
ually the  lumen  of  the  bowel  will  become  restored.  If,  on  fehe  other 
hand,  the  entire  circumference  of  the  bowel  at  the  point  of  flexion 
has  become  fixed  and  immovable  by  inflammatory  adhesions  or  other 
path*  (logical  products,  a  compensating  dilatation  becomes  impossible, 
and  the  flexion  becomes  a  direct  and  serious  cause  of  obstruction. 

3.     Volvulus. 

This  condition,  only  another  form  of  flexion,  was  experimentally 
produced  by  rotating  a  loop  of  intestine  one  and  a  half  or  two  times 
around  its  axis,  and  retaining  it  in  this  position  by  a  number  of  fine 


410  EXPERIMENTAL  SURGERY. 

sutures,  which  were  applied  in  places  at  the  base  of  the  volvulus, 
where  fixation  was  most  required. 

Experiment  11.  Dog,  weight  twelve  pounds.  A  loop  of  the  ileum,  eight 
inches  in  length,  was  brought  out  through  a  small  incision  and  the  tubes 
turned  around  their  axis  twice  and  the  twist  maintained  by  two  catgut 
sutures.  The  constriction  was  sufficiently  firm  to  cause  considerable  venous 
engorgement  in  the  twisted  loop.  The  dog  manifested  no  unpleasant  symptoms 
after  the  operation.  The  specimen  was  not  obtained,  as  after  a  few  days  the 
dog  ran  away. 

Experiment  12.  Medium-sized  adult  cat.  In  this  case  the  volvulus  was 
made  by  twisting  a  loop  of  the  ileum,  about  four  inches  in  length,  twice 
around  its  axis,  and  retaining  it  in  this  position  by  a  number  of  fine  silk 
sutures.  Vomited  several  times  during  the  first  day.  The  first  three  days  in 
taking  the  temperature  in  the  rectum,  the  thermometer  when  taken  out  was 
bloody.  The  first  two  days  the  temperature  was  normal,  followed  by  an 
increase  to  104.6°  and  103.2°  F.  the  two  succeeding  days;  then  it  became 
normal.  No  constipation;  appetite  good  throughout  the  whole  time.  Animal 
killed  twenty-two  days  after  operation.  Abdominal  wound  completely  united; 
no  peritonitis.  Volvulus  remains  as  after  operation,  with  the  exception  that 
where  the  bowel  had  been  flattened  by  the  twisting  it  had,  at  least  partially, 
resumed  its  tubular  form.  Serous  surfaces  where  approximated  had  become 
firmly  adherent  at  point  of  constriction,  size  of  bowel  considerably  diminished. 
The  twisted  loop  contained  liquid  fseces.  Connecting  the  specimen  with  the 
faucet  of  a  hydrant,  water  could  be  forced  through,  but  on  increasing  the 
force  of  the  current  the  peritoneum  ruptured  extensively  in  a  longitudinal 
direction  to  point  of  partial  obstruction. 

Remarks. — -These  experiments  are  interesting,  inasmuch  as  the 
primary  constriction  produced  in  making  and  maintaining  the  volvu- 
lus, which  was  sufficient  to  cause  venous  engorgement  in  the  twisted 
loop,  must  have  been  only  of  short  duration,  the  disappear- 
ance of  the  effects  of  constriction  being  undoubtedly  due  to  the 
gradual  yielding  of  the  sutured  parts.  While  the  faulty  axis  of  the 
twisted  loop  was  maintained  by  the  sutures,  the  circulation  improved 
and  remained  in  a  sufficiently  vigorous  condition  to  adequately 
nourish  the  most  distant  portions  of  the  volvulus.  "While  it  was 
found  difficult  to  force  fluid  through  a  specimen  of  volvulus  during 
life,  propulsion  of  the  intestinal  contents  by  peristaltic  action  was 
carried  on  in  a  satisfactory  manner,  as  the  bowel  above  the  volvulus 
was  not  dilated,  and  contained  no  abnormal  amount  of  fluid,  and  the 
animal  manifested  no  symptoms  indicative  of  intestinal  obstruction. 
4.  Invagination. 
The  most  frequent  and,  from  a  surgical  standpoint,  the  most 
important  form  of  intestinal  obstruction  is  invagination.     Leichten- 


INVA  GIN  A  TION.  4 1 1 

stern  and  Leubuscher  have  made  careful  experimental  studies  to 
explain  the  mechanism  and  pathological  conditions  which  give  rise 
to  this  kind  of  intestinal  obstruction;  but  in  the  following  experi- 
ments this  part  of  the  subject  was  ignored,  and  the  invaginations 
were  made  by  direct  manipulation.  It  was  found  impossible  to 
make  an  invagination  at  any  point,  as  long  as  the  bowel  was  in  a 
condition  of  contraction,  consequently  it  was  always  found  necessary 
to  wait  until  the  peristaltic  wave  had  passed  by,  or  to  cause  relax- 
ation by  firm  pressure  continued  for  several  minutes.  Usually,  it 
was  found  easy  to  produce  an  invagination  of  the  bowel,  when  in  a 
state  of  relaxation,  by  indenting  one  side  of  the  bowel,  and  pushing 
the  pouch  forward  with  a  blunt  instrument  until  the  entire  lumen  of 
the  intestine  had  passed  into  the  section  of  the  bowel  below.  After 
this  was  accomplished,  further  invagination  was  readily  effected  by 
manipulation,  consisting  in  pushing  gently  the  intussusceptum  and 
intussuscipiens  in  opposite  directions.  After  I  had  learned  by 
experience  that  disinvagination  frequently  takes  place  spontaneously, 
I  resorted  sometimes  to  suturing  of  the  intussusceptum  to  the  neck 
of  the  intussuscipiens  for  the  purpose  of  maintaining  the  invagina- 
tion. But  even  this  expedient  did  not  always  succeed  in  retaining 
the  malposition,  as  spontaneous  reduction  was  observed  in  several  of 
these  cases. 

Experiment  13.  Adult  cat.  The  lower  portion  of  the  ileum  and  the 
caecum  and  upper  portion  of  the  colon  were  drawn  forward  into  an  incision 
through  the  linea  alba,  and  five  inches  of  the  ileum  were  pushed  into  the  colon 
through  the  ileo-cascal  valve,  when  the  parts  were  replaced  and  the  abdominal 
wound  closed.  For  six  days  the  animal  had  a  temperature  from  102.6°  to 
105"  F.,  and  suffered  from  tenesmus.  The  stools  contained  mucus  and  blood. 
After  the  sixth  day  the  symptoms  due  to  invagination  subsided,  and  were 
replaced  by  symptoms  of  peritonitis.  The  animal  was  killed  twenty-two  days 
after  operation.  Great  emaciation;  abdominal  wound  completely  united; 
diffuse  purulent  peritonitis.  The  disease  had  evidently  commenced  in  the 
ileo-cascal  region,  as  at  this  point  the  pathological  changes  were  found  most 
advanced.  Complete  spontaneous  reduction  of  the  invagination ;  colon 
greatly  distended,  and  intensely  congested. 

Experiment  14.  Large,  adult  cat.  Invagination  was  made  in  the  lower 
part  of  the  ileum.  Length  of  intussusceptum  three  inches.  For  nine  days 
the  scanty  f;ecal  discharges  contained  mucus  and  at  times  blood.  On  the 
ninth  day  the  temperature  registered  105°  F.  ;  absolute  refusal  of  food,  and 
only  occasional  vomiting;  death  on  the  thirty-third  day  after  invagination. 
Abdominal  wound  healed;  small  vent ral  hernia;  no  peritonitis.  Apparently, 
the  greater  portion  of  the  intussusceptum  bad  disappeared   by  sloughing,  and 


412  EXPERIMENTAL  SURGERY. 

the  subsequent  healing  process  had  produced  an  acute  flexion  at  the  neck  of  the 
intussuscipiens.  Firm  adhesions  between  peritoneal  surfaces  in  the  concavity 
of  the  flexion,  nearly  an  inch  in  length.  Above  this  point  the  intestine  was 
enormously  dilated  and  distended  with  fluid  contents.  Below  the  obstruction 
the  bowel  was  found  contracted  and  empty.  Water  could  not  be  forced 
through  the  obstruction  from  either  direction.  On  slitting  open  the  bowel  in  a 
longitudinal  direction,  it  was  found  that  the  lumen  at  the  point  of  flexion  was 
contracted  to  such  an  extent  that  only  a  fine  probe  could  be  passed.  On  the 
concave  side  of  the  flexion  the  mucous  membrane  presented  a  prominence 
marked  by  a  number  of  longitudinal  ridges.  These  folds  had  undoubtedly 
acted  like  valves  in  completely  preventing  the  passage  of  intestinal  contents, 
and  later,  the  injection  of  water.  Death  in  this  case  resulted  from  intestinal 
obstruction  caused  by  cicatricial  contraction  after  the  sloughing  of  the  invagi- 
nated  portion  of  the  bowel. 

Experiment  15.  Adult  cat.  Two  inches  of  the  ileum  were  invaginated 
into  the  colon  and  fixed  by  two  fine  silk  sutures  at  the  neck  of  the  intussus- 
cipiens. For  two  days  after  the  invagination  the  stools  were  scanty  and 
contained  mucous  and  blood.  On  the  third  day  the  abdominal  cavity  was 
re-opened  by  an  incision  along  the  outer  border  of  the  right  rectus  muscle,  and 
the  invaginated  bowel  drawn  forward  into  the  wound.  No  peritonitis.  The 
bowel  at  point  of  operation  was  very  vascular,  and  the  neck  of  the  intussus- 
cipiens covered  with  plastic  exudation.  The  sutures  were  removed  and  the 
rectum  and  colon  distended  with  water  for  the  purpose  of  effecting  reduction. 
As  soon  as  the  colon  had  become  thoroughly  distended  the  adhesions  gave 
way  with  an  audible  noise,  and  complete  reduction  followed  in  such  a  manner 
that  the  portion  last  invaginated  was  first  reduced.  After  reduction  had  been 
accomplished  the  injection  was  continued  to  test  the  competency  of  the  ileo- 
cecal valve.  As  soon  as  the  caecum  was  well  distended  the  fluid  passed  readily 
through  the  valve  into  the  small  intestines,  showing  that  the  valve  had  been 
rendered  incompetent  by  the  invagination.  The  force  required  to  overcome 
the  adhesions  in  the  reduction  of  the  invagination  was  sufficient  to  rupture 
the  peritoneal  covering  of  the  large  intestines  in  three  different  places,  the 
rents  always  taking  place  parallel  to  the  bowel.  The  animal  died  on  the 
following  day  with  symptoms  of  diffuse  peritonitis. 

Experiment  16.  Ascending  invagination  in  a  cat.  A  few  inches  nbove 
the  ileo-csecal  region  the  ileum  was  invaginated  in  an  upward  direction  to  the 
extent  of  two  inches.  At  the  time  the  invagination  was  made  the  intussus- 
cipiens contracted  firmly.  In  consequence  of  this,  a  tear  occurred  in  its  peri- 
toneal covering  in  a  direction  parallel  to  the  bowel.  The  stools  were  few  and 
scanty.  On  the  fourth  day  the  animal  died  of  perforative  peritonitis.  Abdom- 
inal wound  not  united,  but  the  peritoneal  wound  closed  by  omental  adhesions. 
Spontaneous  reduction  of  half  an  inch  of  the  invagination  had  taken  place. 
Reduction  by  traction  was  found  impossible  on  account  of  firm  adhesions 
about  the  neck  of  the  invagination.  Recent  diffuse  peritonitis  caused  by  two 
perforations,  one  at  the  neck  of  the  intussusceptum  on  mesenteric  side,  and 
the  other  a  little  to  one  side  of  this  one  and  on  proximal  side  of  the  bowel. 


IN  VA  GIN  A  TION.  4 1 3 

The  perforation  resulted  from  beginning  sloughing  of  the  invaginated  portion 
of  the  bowel.  About  two  inches  above  the  invagination  the  bowel  was  acutely- 
flexed  towards  the  mesenteric  side  by  recent  firm  adhesions.  Flexion  was 
undoubtedly  caused  by  circumscribed  plastic  peritonitis  and  increased  peri- 
stalsis. 

Experiment  17.  Large,  adult  cat.  Descending  invagination  of  ileum  to 
the  extent  of  two  inches  in  the  upper  portion  of  this  part  of  the  bowel. 
Second  and  third  days  the  scanty  discharges  from  the  bowel  bloody.  Temper- 
ature from  second  day  after  operation  varied  between  "103.4°  and  105.4°  F. 
Death  from  perforative  peritonitis  on  the  seventh  day  after  invagination. 
Abdominal  wound  united.  Recent  diffuse  peritonitis  from  a  perforation  at 
the  neck  of  the  invagination  on  the  mesenteric  side.  Gangrene  of  intussus- 
ceptum  and  partial  separation  which  had  again  caused  a  sharp  flexion  of  the 
bowel  at  the  neck  of  the  invagination.  Above  the  seat  of  obstruction  the 
bowel  dilated  and  distended  with  fluid  contents;  below  empty  and  contracted. 

Experiment  18.  Young  cat.  Invagination  of  ileum  into  ascending  colon 
to  the  extent  of  three  inches.  For  a  week  after  operation  frequent  tenesmus, 
followed  by  mucous  discharges  mixed  with  blood.  The  temperature  during 
this  time  varied  from  102.6°  to  105°  F.  After  this  the  animal  improved  and 
■was  in  good  condition  when  killed  fourteen  days  after  operation.  Abdominal 
wound  united.  No  omental  adhesions  or  peritonitis.  Firm  union  between  the 
serous  surfaces.  No  dilatation  of  bowel  above  seat  of  obstruction.  Intussus- 
ceptum  not  gangrenous,  its  lumen  about  the  size  of  an  ordinary  lead-pencil. 
It  was  found  impossible  to  reduce  the  invagination  by  traction  or  by  forcible 
injection  of  fluid  from  below.  When  the  traction  was  increased,  the  peritoneal 
surface  of  the  neck  of  the  intussuscipiens  ruptured  in  a  longitudinal  direction. 

Experiment  19.  Large,  adult  cat.  Six  inches  of  the  ileum  were  invagi- 
nated into  the  colon.  Frequent  bloody  discharges  until  the  third  day,  when 
the  abdomen  was  reopened  and  the  neck  of  the  intussuscipiens  exposed  to 
sight,  so  as  to  observe  directly  the  mechanism  of  disinvagination  by  rectal 
injection  of  water.  A.s  soon  as  the  colon  was  well  distended  the  adhesions  at 
the  neck  of  the  intussuscipiens  began  to  give  way,  and  complete  reduction 
followed,  as  the  adhesions  gave  way  under  the  pressure  from  below.  The 
abdominal  wound  was  again  closed  and  dressed  in  the  usual  manner.  The 
animal  recovered  completely  from  t^e  operation,  and  was  killed  twenty-four 
days  after  the  first  operation.  Abdominal  wound  well  united.  In  the  ileo- 
csecal  region,  numerous  adhesions  around  the  portion  of  bowel  which  had  been 
invaginated  and  subsequently  reduced. 

Experiment  20.  Invagination  of  colon  into  colon  was  commenced  about 
the  middle  of  the  bowel,  and  advanced  as  far  as  the  caecum.  Second  day  bloody 
discharges  from  the  bowels.  Animal  killed  five  days  after  operation.  External 
wound  united  only  on  peritoneal  side.  Invagination  completely  reduced. 
Localized  plastic  peritonitis  limited  to  the  portion  of  the  bowel  which  had 
been  invaginated;  otherwise  peritoneum  and  intestines  in  a  healthy  condition. 

Experiment  21.  Invagination  of  colon  into  colon  to  the  extent  of  four 
inches,  in  a  cat.     The  subsequent  symptoms  only  for  a  short  time  indicated 


414  EXPERIMENTAL  SURGERY. 

the  existence  of  invagination,  which  after  they  had  subsided,  were  followed  by 
evidence  of  peritonitis.  Death  occurred  on  the  nineteenth  day  after  the 
invagination.  Abdominal  wound  well  united;  diffuse  purulent  peritonitis; 
under  surface  of  diaphragm*  covered  with  plastic  lymph.  Although  sought 
for,  no  perforation  could  be  found  in  the  disinvaginated  bowel,  but  as  the 
peritonitis  appeared  to  have  started  at  the  site  of  operation,  it  is  probable 
that  infection  took  place  through  the  paretic  walls  of  the  disinvaginated  bowel. 

Experiment  22.  Same  kind  of  invagination  made  in  a  cat  as  in  the 
preceding  case.  For  two  days  the  stools  were  frequent,  scanty,  and  contained 
mucus  and  blood.  After  this  the  animal  remained  in  good  condition  until  it 
was  killed  thirty-five  days  after  the  invagination.  Abdominal  cavity  showed 
no  trace  of  inflammation.  The  invagination  was  completely  reduced  and  the 
entire  colon  presented  a  normal  appearance. 

Remarks. — With  the  exception  of  experiment  No.  16,  the  in- 
vagination was  always  made  in  a  downward  direction.  In  the  case 
of  ascending  invagination,  gangrene  of  the  intussusceptum  and 
perforation  resulted  in  death  from  diffuse  peritonitis  on  the  fourth 
day  after  partial  spontaneous  reduction  had  taken  place.  In  experi- 
ments Nos.  15  and  19,  both  cases  of  ileo-csecal  invagination, 
complete  reduction  was  effected  by  distention  of  the  colon  with 
water ;  in  the  first  case  the  force  required  to  accomplish  this  result 
was  sufficient  to  produce  multiple  longitudinal  lacerations  of  the 
peritoneal  surface  of  the  distended  bowel,  which  undoubtedly  were 
responsible  for  the  death  on  the  following  day  from  diffuse  perito- 
nitis ;  while  in  the  second  case  no  such  accident  occurred,  and  the 
animal  recovered,  although  the  abdominal  wound  was  re-opened  for 
the  purpose  of  observing  the  mechanism  of  reduction  by  this  method 
of  procedure.  In  one  case  of  ileo-csecal  invagination,  experiment 
No.  18,  the  intussusceptum  remained  in  situ  after  the  invagination, 
and  became  so  firmly  adherent  to  the  intussuscipiens  that  even  in 
the  specimen,  reduction  by  traction  was  found  impossible.  In  this 
case,  although  the  lumen  of  the  invaginated  portion  barely  permitted 
the  introduction  of  an  ordinary  lead  pencil,  no  symptoms  of  obstruc- 
tion were  manifested  during  life,  and  the  bowel  above  the  invagina- 
tion was  not  found  dilated  after  death.  In  experiment  No.  14,  the 
sloughing  of  the  intussusceptum  led  to  cicatricial  contraction  of  the 
bowel  and  flexion  at  site  of  invagination,  conditions  which  resulted 
in  death  from  obstruction  twenty-three  days  after  invagination. 

The  great  danger  which  attends  sloughing  of  the  invaginated 
portion  is  circumscribed  gangrene  and  perforation  of  the  intussus- 
cipiens  at   the   neck,   and   death  from   perforative  peritonitis,  as 


PERMEABILITY   OF  ILEO-CJECAL    VALVE.  415 

illustrated  by  experiments  Nos.  16  and  17.  Experiment  No.  16 
illustrates  that  ascending  invagination,  should  it  occur,  is  not  more 
likely  to  be  reduced  spontaneously  than  the  more  common  form  of 
descending  invagination.  These  experiments  also  demonstrate 
conclusively  that  the  danger  attending  the  invagination  increases  the 
higher  it  is  located  in  the  intestinal  canal,  being  greatest  when  it  is 
situated  high  up  in  the  tract  of  the  small  intestines,  and  gradually 
less  as  the  ileo-caecal  region  is  approached.  The  ileo-csecal  form  is 
less  dangerous,  as  spontaneous  reduction  is  more  likely  to  take 
place;  and  gangrene  of  the  intussusceptum,  when  it  occurs,  does  so 
after  a  longer  time,  after  firm  adhesions  about  the  neck  of  the  intus- 
suscipiens  have  formed,  a  condition  which  is  well  adapted  to  prevent 
perforation.  Of  the  three  invaginations  of  the  colon,  experiments 
Nos.  20,  21  and  22,  complete  spontaneous  reduction  took  place  in 
all  of  them  from  the  first  to  the  fourth  day,  and  in  only  one  of  them 
was  the  result  fatal,  in  experiment  No.  21,  where  purulent  perito- 
nitis, either  from  infection  through  the  operation  wound  or,  what  is 
more  probable,  through  the  damaged  wall  of  the  colon  occurred, 
and  was  the  cause  of  death  on  the  nineteenth  day  after  the  invagi- 
nation. Experiments  Nos.  15  and  19  prove  both  the  danger  and 
the  utility  of  distention  of  the  colon  in  cases  of  ileo-csecal  and 
colonic  invaginations.  As  a  rule,  the  longer  the  invagination  has 
existed  the  firmer  the  adhesions,  and  consequently  the  greater  the 
danger  of  relying  too  persistently  on  this  measure  in  reducing  the 
invagination.  In  resorting  to  this  expedient  in  the  reduction  of  an 
ileo-cffical  invagination,  it  is  of  the  greatest  importance  to  relax  the 
abdominal  wall  completely  by  placing  the  patient  fully  under  the 
influence  of  an  anaesthetic;  and  to  add  to  the  distending  force  as 
much  as  possible  by  gravitation,  the  patient  should  be  inverted  and 
the  injection  should  always  be  made  very  slowly  and  with  requisite 
care  to  prevent  rupture  of  the  peritoneal  coat  by  rapid  over-disten- 
tion.  When  the  obstruction  is  located  beyond  the  ileo-caecal  valve, 
no  reliance  can  be  placed  upon  this  measure,  as  can  be  seen  from 
the  following  experiments  made  to  determine  the 

Permeability  of  the  Ileo-Caecal  Valve. 

Experiment.  23.  While  completely  under  the  influence  of  ether  an  incision 
was  made  through  the  linea  alba  of  a  cat,  sufficiently  long  to  render  the 
ileo-osecal  region  readily  accessible  to  sight.  An  incision  was  made  into 
the  ileum  just  above  the  valve,  and  by  gently  retracting  the  margins  of  the 


416  EXPERIMENTAL  SURGERY. 

wound,  the  valve  could  be  distinctly  seen;  water  was  then  injected  per  rectum, 
and  as  the  caacuru  became  well  distended,  it  could  be  readily  seen  that  the  valve 
became  tense  and  appeared  like  a  circular  curtain  preventing  effectually  the 
escape  of  even  a  drop  of  fluid  into  the  ileum.  The  competency  of  the  valve 
was  only  overcome  by  over-distention  of  the  caecum  which  mechanically 
separated  its  margins,  which  allowed  a  fine  stream  of  water  to  escape  into  the 
ileum.  The  insufficiency  of  the  valve  was  clearly  caused  by  great  distention 
of  the  caecum.  That  such  a  degree  of  distention  is  attended  by  no  incon- 
siderable danger  was  proved  by  this  experiment,  as  the  cat  was  immediately 
killed,  and  on  examination  of  the  colon  and  rectum  a  number  of  longitudinal 
rents  of  the  peritoneal  coat  were  found. 

Experiment  24.  In  this  experiment,  a  cat  was  fully  narcotized  with  ether 
and  while  the  body  was  inverted  water  was  injected  per  rectum  in  sufficient 
quantity,  and  adequate  force  by  means  of  an  elastic  syringe,  to  ascertain  the 
force  required  to  overcome  the  resistance  offered  by  the  ileo-csecal  valve. 
Great  distention  of  the  caecum  could  be  clearly  mapped  out  by  percussion  and 
palpation  before  any  fluid  passed  into  the  ileum.  As  soon  as  the  competency 
of  the  valve  was  overcome,  the  water  rushed  through  the  small  intestines, 
and  having  traversed  the  entire  alimentary  canal  issued  from  the  mouth. 
About  a  quart  of  water  was  forced  through  in  this  manner.  The  animal  was 
killed  and  the  gastro-intestinal  canal  carefully  examined  for  injuries.  Two 
longitudinal  lacerations  of  the  peritoneal  surface  of  the  rectum,  over  an  inch 
in  length,  were  found  on  opposite  sides  of  the  bowel. 

Experiment  25.  This  experiment  was  conducted  in  the  same  way  as  the 
foregoing,  only  that  the  cat  was  not  etherized.  More  than  a  quart  of  water 
was  forced  through  the  entire  alimentary  canal  from  anus  to  mouth.  The 
animal  was  not  killed,  and  lived  for  eight  days,  but  suffered  the  whole  time 
with  symptoms  of  ileo-colitis.  A  post-mortem  examination  was  not  made  in 
this  case,  although  the  symptoms  manifested  during  life  leave  no  doubt  that 
they  resulted  from  injuries  inflicted  by  the  injection.  It  will  thus  be  seen 
that  in  the  three  cases  where  fluid  was  forced  beyond  the  ileo-caecal  valve,  in 
two  of  them  the  post-mortem  examination  revealed  multiple  lacerations  of 
the  peritoneal  coat  of  the  large  intestines,  while  the  third  animal  sickened 
immediately  after  the  experiment  was  made,  and  died  from  tho  effects  of  the 
injuries  inflicted  eight  days  later.  The  injection  of  water  beyond  the  ileo- 
caecal  valve  in  the  treatment  of  intestinal  obstruction  must  therefore  be  looked 
upon  in  the  light  of  a  dangerous  expedient  and  should  never  be  resorted  to. 

II.    Enter  ectoniy. 

It  still  remains  an  open  question  to  what  extent  resection  of  the 
small  intestines  can  be  performed  with  impunity.  It  is  true  that 
Koeberl£,  Kocher  and  Baum  have  successfully  removed  respectively 
205  cm.,  160  cm.,  and  137  cm.  of  the  small  intestine  in  the  human 
subject;  but  while  two  of  the  patients  do  not  appear  to  have  suffered 
any  ill  effects  in  consequence  of  the  removal  of  such  a  large  surface 


ENTERECTOMY.  417 

for  digestion  and  absorption,  in  Baum's  case  death,  which  super- 
vened six  months  after  the  operation,  was  attributable  clearly  to 
marasmus,  brought  about  by  the  extensive  intestinal  resection.  As 
in  a  number  of  pathological  conditions  of  the  intestinal  canal,  where 
the  wounds  are  large  and  in  close  proximity,  such  as  multiple  strict- 
ures, gangrene,  and  multiple  gunshot  wounds,  it  may  be  necessary 
to  resort  to  extensive  resection,  it  becomes  an  important  matter  for 
the  surgeon  to  know  how  much  of  the  intestinal  tract  can  be  removed 
without  any  immediate  or  remote  ill  consequences. 

The  immediate  danger  attending  such  an  operation  is  the 
traumatism,  which  of  course,  will  be  proportionate  to  the  length  of 
the  piece  of  intestine  removed;  while  the  remote  consequences  are 
due  to  impairment  of  the  functions  of  digestion  and  absorption 
caused  by  the  shortening  of  the  intestinal  canal.  With  the  view  of 
obtaining  additional  light  on  these  important  questions  the  following 
experiments  were  undertaken : 

Experiment  26.  Dog,  weight  twenty-two  pounds.  Mesentery  divided  into 
four  portions  and  tied  with  catgut,  and  thirty  inches  of  the  ileum  from  near 
the  ileo-csecal  region  upwards  excised,  and  ends  sutured  together  by  Czerny- 
Lembert  sutures.  Abdominal  wound  failed  to  unite,  and  a  copious  sei-o- 
sanguinolent  discharge  escaped  from  it  the  last  day.  Death  on  fifth  day  from 
peritonitis.  Peritoneal  adhesions  in  abdominal  wound  only  partial;  omentum 
adherent  to  wound.  Intestines  firmly  adherent  to  omental  stump.  Circum- 
scribed gangrene  of  bowel  on  convex  side  at  site  of  operation.  Recent  diffuse 
peritonitis  caused  by  perforation. 

Experiment  27.  In  a  cat,  twelve  inches  were  removed  from  the  middle  of 
the  ileum,  and  the  ends  united  by  a  double  row  of  sutures;  mesenteric  vessels 
tied  en  masse  with  one  catgut  suture.  The  animal  never  rallied  from  the 
operation,  and  died  of  the  shock  the  same  night. 

Experiment  28.  Dog,  weight  thirty-six  pounds.  Mesentery  tied  in  several 
sections  with  catgut  ligatures;  ileum  divided  just  above  the  ileo-cascal  valve 
and  six  feet  of  the  small  intestines  excised,  and  the  ends  united  by  Czerny- 
Lembert  sutures.  On  the  third  day  the  ftecal  discharges  were  bloody.  Although 
the  appetite  remained  good,  and  the  dog  was  allowed  to  eat  as  much  as  he 
desired,  he  lost  several  pounds  in  weight  during  the  first  week.  On  the  third 
day  the  abdominal  wound  opened  as  the  sutures  had  cut  through  and  required 
re-suturing.  After  this  time  the  wound  healed  kindly.  Three  or  four  fluid 
faecal  discharges  during  twenty-four  hours.  The  character  of  the  discharges 
remained  the  same,  and  several  microscopic  examinations  made  at  different 
times  revealed  the  presence  of  free  undigested  fat.  The  dog  was  kept  busy  eat- 
ing most  of  the  time,  and  although  the  most  nourishing  food  was  furnished,  he 
emaciated  to  a  skeleton.  Ho  was  killed  one  hundred  and  sixty-one  days  after 
the  operation.     Marasmus  extreme,  hardly  a  trace  of  fat  could  be  found  any- 


418  EXPERIMENTAL  SURGERY. 

where  in  the  tissues.  Stomach  enlarged  to  three  or  four  times  its  normal  size, 
and  distended  with  food.  A  slight  thickening  of  the  wall  of  the  gut  indicated 
externally  the  site  of  suturing,  and  the  lumen  of  the  bowel  at  this  point  was 
slightly  diminished  in  size.  At  point  of  operation  a  loop  of  intestine  was 
found  adherent  and  somewhat  contracted.  The  remaining  portions  of  the 
small  intestines,  only  forty-five  inches  in  length,  seemed  to  have  undergone 
compensatory  hypertrophy,  as  the  coats  were  much  thickened  and  exceedingly 
vascular.  At  the  seat  of  suturing,  the  mucous  membrane  presented  a  slight 
circular  prominence.  Pancreas,  liver  and  spleen  were  normal  in  size  and 
appearance. 

Experiment  29.  Medium-sized,  adult  dog.  Mesentery  tied  in  several 
sections,  and  eight  feet  and  two  inches  of  the  small  intestines  from  ileo-caecal 
region  upwards  excised  and  ends  sutured  in  the  usual  manner.  On  the  follow- 
ing day  the  dog  vomited,  and  blood  was  seen  to  escape  from  the  abdominal 
wound.  Death  three  days  after  operation.  The  abdominal  cavity  was  filled 
with  fluid  and  coagulated  blood,  which  on  closer  inspection  was  found  to  have 
escaped  from  one  of  the  stumps  of  the  mesentery,  where  the  catgut  ligature 
had  slipped  off. 

Experiment  30.  Scotch  terrier,  weight  ten  pounds.  Mesentery  ligated  in 
part  with  catgut  ligatures,  the  ileum  divided  four  inches  above  the  ileo- 
caecal  region,  and  fifty  inches  of  the  small  intestines  excised,  and  the  continu- 
ity of  the  intestinal  canal  restored  by  the  usual  method  of  suturing.  Some 
difficulty  was  experienced  in  suturing,  as  the  lumen  of  the  upper  end  was 
considerably  larger  than  that  of  the  lower.  Until  four  weeks  after  the  opera- 
tion the  dog,  although  eating  well,  seemed  to  become  more  and  more  emaci- 
ated. After  this  time  he  gained  somewhat  in  weight  until  killed  forty-seven 
days  after  the  resection.  During  the  whole  time  the  fasces  were  either  fluid 
or  only  semi-solid,  and  at  different  times  contained  free,  undigested  fat. 
Appetite  most  of  the  time  voracious.  No  adhesions  to  abdominal  wound. 
Omentum  adherent  to  visceral  wound  and  to  bowel.  The  site  of  operation  was 
indicated  by  a  slight  depression  on  the  surface  of  the  bowel.  On  palpation  a 
ring-like  thickening  was  felt  corresponding  to  the  united  ends  of  the  bowel. 
Bowel  above  seat  of  resection  somewhat  enlarged.  On  cutting  into  the  bowel 
the  point  of  union  was  indicated  by  a  circular  prominence  of  mucous  mem- 
brane. Nine  of  the  deep  sutures  were  found  still  attached  to  the  mucous 
membrane.  The  entire  tract  of  the  small  intestines  which  remained  measured 
only  two  feet  and  ten  inches  in  length. 

Experiment  31.  Adult  Maltese  cat.  The  mesentery  was  tied  in  five 
sections  with  catgut  ligatures  corresponding  to  twenty-nine  inches  of  the 
ileum  which  was  excised.  Previous  experience  in  circular  enterorrhaphy  had 
satisfied  me  that  perforation  is  most  likely  to  take  place  on  the  mesenteric 
side  of  the  bowel,  where,  on  account  of  the  triangular  place  made  by  the 
reflections  of%the  peritoneum,  the  muscular  coat  is  not  covered  by  serous 
membrane.  To  obviate  this  difficulty  I  secured  a  continuity  of  the  serous 
covering  of  the  ends  of  the  bowel  before  suturing,  by  drawing  the  peritoneum 
over  this  raw  surface  by  a  tine  catgut  suture.     The  mesentery  was  detached 


EXCISION  OF  COLON.  4  1  'J 

only  to  a  sufficient  extent  to  apply  the  second  row  of  sutures.  The  fine  catgut 
suture  to  approximate  the  edges  of  the  peritoneum  was  applied  near  the 
margin  of  the  divided  end  of  the  bowel,  so  that  the  knot  did  not  interfere 
with  the  accurate  coaptation  of  the  serous  surface  between  the  deep  and 
superficial  row  of  sutures.  This  modification  of  circular  suturing  was  adopted 
for  the  first  time  in  this  case.  Although  the  animal  manifested  no  untoward 
symptoms,  and  the  appetite  remained  good,  the  marasmus  was  progressive 
until  the  time  of  killing,  twelve  days  after  the  excision.  Abdominal  wound 
not  completely  united.  Intestinal  wound,  which  was  two  inches  above  the 
ileo-caacal  region,  completely  healed.  The  sutured  surface  was  adherent  to  a 
loop  of  bowel  which  caused  a  sharp  flexion.  Intestine  above  this  point  some- 
what dilated  and  partially  distended  with  faecal  accumulation.  Slight  contrac- 
tion of  the  lumen  of  bowel  by  circular  bulging  of  mucous  membrane,  in 
which  most  of  the  deep  sutures  remained  fixed.  The  post-mortem  appear- 
ance pointed  to  partial  obstruction  at  point  of  flexion;  remaining  portion  of 
small  intestines  measured  only  twenty-one  inches  in  length. 

Experiment  32.  Medium-sized  Maltese  cat.  Mesentery  tied  in  sections, 
and  thirty-four  inches  of  the  small  intestines  excised  and  the  divided  ends 
united  in  the  same  manner  as  in  the  last  case,  special  care  being  taken  to 
secure  an  uninterrupted  peritoneal  surface  for  divided  ends  before  suturing. 
Appetite  remained  good,  but  progressive  marasmus,  which  appeared  at  once, 
continued  and  proved  the  direct  cause  of  death  twenty-one  days  after  the 
excision.  Abdominal  wound  firmly  united.  No  peritonitis.  Visceral  wound 
completely  united;  intestine  at  site  of  operation  covered  with  adherent 
omentum. 

I.     Excision  of  Colon. 

Experiment  33.  Large,  black  cat.  The  meso-colon  was  divided  in  numer- 
ous sections,  and  each  part  separately  tied  with  a  catgut  ligature.  As  the 
meso-colon  was  very  short,  a  number  of  the  ligatures  slipped  off  and  had  to  be 
replaced  by  fine  silk  ligatures.  The  entire  colon  and  about  two  inches  of  the 
lower  end  of  the  ileum  were  excised.  As  it  was  found  impossible  to  unite  the 
bowel  on  account  of  the  deep  location  of  the  rectal  end,  it  became  necessary 
to  close  the  distal  or  rectal  end  by  inverting  its  margins  and  applying  a 
continuous  suture.  An  artificial  anus  was  established  by  stretching  the  iliac 
or  proximal  end  into  the  abdominal  wound.  Death  from  shock  a  few  hours 
after  the  operation. 

Experiment  34.  Medium-sized  dog.  Resection  of  entire  colon  and  three 
inches  of  ileum.  Meso-colon  divid  d  into  sections  and  ligated  with  silk 
ligatures.  In  order  to  enabl 3  circular  enterorrhaphy  it  was  found  necessary  to 
excise  a  triangular  piece  from  large  distal  end,  so  as  to  make  its  lumen  corres- 
pond to  that  of  the  divided  ileum.  After  this  was  done  and  the  lateral  wound 
closed  by  two  rows  of  sutures,  the  ends  of  the  bowel  were  united  in  the  usual 
manner.     Death  from  shock  six  hours  after  operation. 

ExperXment  35.  Excision  of  entire  colon  and  two  inches  of  ileum  in  a 
cat.     Excision  of  triangular  piece  from  distal  end,  to  narrow  the  bowel  suffi- 


420  EXPERIMENTAL  SURGERY. 

ciently  so  that  its  lumen  should  correspond  to  that  of  the  ileum.  The  ileum 
and  rectum  were  then  united  by  Czerny-Lembert  sutures.  The  animal  never 
rallied  from  the  prolonged  operation,  and  died  of  shock4two  hours  later. 

Remarks. — The  results  of  these  experiments  speak  for  them- 
selves. In  all  cases  of  extensive  resection  of  the  small  intestines 
where  the  resected  portion  exceeded  one-half  of  the  length  of  this 
portion  of  the  intestinal  tract,  where  the  animals  survived  the 
operation,  marasmus  followed  as  a  constant  result,  although  the 
animals  consumed  large  quantities  of  food.  In  all  of  these  cases 
defective  digestion  and  absorption  could  be  directly  attributed  to  a 
degree  of  shortening  of  the  digestive  canal  imcompatible  with 
normal  digestion  and  absorption.  Only  one  of  these  animals 
(experiment  No.  27)  died  from  shock  a  few  hours  after  operation. 
Another  death  resulted  from  the  trauma,  in  experiment  No.  29, 
where  fatal  haemorrhage  occurred  from  one  of  the  mesenteric  vessels, 
where  the  catgut  ligature  became  displaced  from  shrinkage  of  the 
included  mesenteric  tissues.  When  the  vessels  of  the  omentum  or 
mesentery  are  tied  en  masse  there  is  always  danger  from  this  source, 
and  to  prevent  this  accident  it  becomes  necessary  not  to  include  too 
much  tissue,  and  to  tie  firmly  with  fine  threads  of  aseptic  silk. 
After  I  commenced  to  tie  in  this  manner,  I  encountered  no  further 
difficulty  in  arresting  and  preventing  haemorrhage  in  operations 
requiring  incision  of  these  tissues.  Although  the  large  artery 
running  parallel  with  the  bowel  where  the  mesentery  is  attached  was 
excised  in  every  case  with  the  intestine,  gangrene  and  perforation 
occurred  only  in  experiment  No.  26.  The  post-mortem  appearances 
after  extensive  enterectomies  indicated  that  the  portion  of  bowel 
which  remained  underwent  compensatory  hypertrophy,  but  that  as  a 
rule  the  increased  functional  activity  was  not  adequate  to  make  up  for 
the  great  anatomical  loss.  In  all  instances  where  the  animal  recovered 
from  the  operation,  the  discharges  from  the  bowels  were  frequent, 
fluid  or  semi-fluid,  and  contained  undigested  food,  among  other 
substances,  free  undigested  fat,  showing  that  the  intestinal  secretions 
play  an  important  role  in  the  digestion  of  fat.  As  an  approximate 
estimate  the  statement  can  be  ventured  that  in  dogs  and  cats,  the 
excision  of  more  than  one-third  of  the  length  of  the  small  intestines 
is  dangerous  to  life,  as  it  is  followed  by  marasmus,  which  sooner  or 
later  results  in  death.  As  all  three  cases  of  excision  of  the  colon 
proved  fatal  from  shock  in  from  two  to  six  hours,  it  can  be  safely 


PHYSIOLOGICAL   EXCLUSION.  421 

asserted   that   this   operation    is    impracticable,    and    is    invariably 
followed  by  death  from  the  immediate  results  of  the  trauma. 

2.     Physiological  Exclusion. 

As  extensive  resections  of  the  intestines  are  always  attended  by . 
great  risks  to  life  from  the  trauma,  I  concluded  to  study  the  subject 
of  sudden  deprivation  of  the  system  of  a  great  surface  for  digestion 
and  absorption,  by  eliminating  or  diminishing  the  cause  of  death  from 
this  source  by  leaving  the  intestine,  but  by  excluding  permanently 
a  certain  portion  from  participating  in  the  functions  of  digestion  and 
absorption;  in  other  words,  by  resorting  to  physiological  exclusion. 
These  experiments  were  also  made  to  determine  the  tissue  changes 
which  would  take  place  in  the  bowel  thus  excluded,  and  to  learn  if 
under  such  circumstances  accumulation  of  intestinal  contents  would 
become  a  source  of  danger,  as  had  been  feared  by  the  older  surgeons. 
The  complete  interruption  of  passage  of  intestinal  contents  either  bi- 
section and  closure  of  the  bowel,  or  by  making  an  intestinal  obstruc- 
tion of  some  kind,  and  the  restoration  of  the  continuity  of  the 
physiologically  active  portion  of  the  intestinal  canal,  was  established 
by  suturing  the  proximal  end  of  the  high  section  with  the  distal 
end  of  the  lower  section,  or  by  implanting  the  proximal  end  into  the 
bowel  lower  down,  the  intervening  portion  of  the  intestinal  tract  in 
either  case  thus  becoming  the  excluded  portion. 

Experiment  36.  Large  cat,  weight  nine  pounds.  Double  division  of  small 
intestines,  upper  section  made  about  eight  inches  below  the  pylorus,  and 
the  lower  three  feet  lower  down;  the  portion  of  bowel  between  these  circular 
sections  was  closed  at  both  ends,  and  the  continuity  of  the  intestinal  canal 
restored  by  suturing  the  open  ends  in  the  usual  manner.  In  this  way  three 
feet  of  the  small  intestines  were  isolated  and  completely  excluded  from  the 
digestive  canal.  The  intervening  portion  was  emptied  of  its  contents  as 
completely  as  possible  before  its  ends  were  closed  by  suturing.  The  animal 
died  on  the  fourth  day  after  the  operation.  A  small  perforation  of  the  sutured 
bowel  on  the  mesenteric  side  was  found,  otherwise  the  visceral  wound  was 
found  well  united.  The  perforation  had  given  rise  to  diffuse  peritonitis  which 
was  the  immediate  cause  of  death. 

Experiment  37.  Dog,  weight  thirty-two  pounds.  The  jejunum  was  divided 
four  feet  above  the  ileo-caecal  region,  and  the  distal  end  closed.  Jejuno-colos- 
tomy  was  made,  by  implanting  the  proximal  end  in<<>  a  slit  made  in  the 
convex  side  of  the  ascending  colon,  large  enough  to  correspond  to  the 
circumference  of  the  jejunum.  The  implanted  end  was  fixed  in  its  position 
by  two  rows  of  sutures.  The  animal  never  appeared  to  rally  from  the  effects 
of  the  operation,  and  died  at  the  end  of  the  next  day.     The  abdominal  cavity 


422  EXPERIMENTAL  SURGERY. 

was  found  filled  with  blood,  which  must  have  escaped  from  a  mesenteric 
vessel,  from  which  probably  the  catgut  ligature  had  slipped.  The  excluded 
portion,  that  is,  that  portion  intervening  between  the  circular  section  and  the 
point  of  implantation,  was  found  quite  empty  of  intestinal  contents,  but 
slightly  distended  with  gas.  Implanted  end  perfectly  retained  by  sutures,  and 
slight  adhesions  between  serous  surfaces  had  already  taken  place.  Death  in 
this  case  was  the  result  of  secondary  haemorrhage. 

Experiment  38.  Dog,  weight  thirty -five  pounds.  Divided  the  ileum  just 
above  the  ileo  caBcal  region,  and  closed  both  ends  of  the  bowel.  Ileo-colostomy 
was  done  by  making  an  incision  about  an  inch  and  a  half  in  length  on  concave 
side  of  ileum,  forty-four  inches  above  the  division,  and  a  similar  slit  on  convex 
side  of  ascending  colon,  and  uniting  these  wounds  by  Czerny-Lembert  sutures, 
thus  excluding  from  the  intestinal  circulation  forty  four  inches  of  the  bowel. 
The  day  after  the  operation  the  faeces  contained  blood.  During  the  progress 
of  the  case  it  was  frequently  noted  that  the  stools  were  thin,  sometimes  liquid. 
Appetite  remained  good,  and  the  animal  was  well  nourished  at  the  time 
of  killing,  twenty-five  days  after  operation.  Abdominal  wall  well  united.  The 
omentum  and  a  few  intestinal  loops  adherent  to  inner  surface  of  wound. 
The  excluded  portion  contracted  to  more  than  one-half  of  its  usual  size, 
atrophic,  and  not  nearly  as  vascular  as  remaining  portion  of  intestinal  canal, 
the  two  blind  ends  adherent  to  each  other  and  to  adjacent  loops.  The  excluded 
portion  contained  in  its  blind  end  a  few  sharp  fragments  of  bone.  The  new 
opening  between  the  ileum  and  colon,  about  the  capacity  of  the  lumen  of  the 
ileum,  surrounded  by  a  prominent  margin  of  mucous  membrane,  which  some- 
what resembled  the  ileo-csecal  valve  to  which  still  remained  attached  about  ten 
of  the  deep  sutures.  The  coats  of  both  bowels  at  points  of  approximation 
thickened  by  inflammatory  exudation. 

Experiment  39.  Young  cat.  The  ileum  was  divided  about  thirty  inches 
above  the  ileo-caecal  region;  the  distal  end  closed  and  proximal  end  laterally 
implanted  into  the  convex  side  of  the  transverse  colon,  where  it  was  fixed  by 
a  double  row  of  sutures.  Before  implantation,  the  continuity  of  the  peritoneal 
surface  was  procured  by  drawing  the  peritoneum  with  a  fine  catgut  suturo 
over  the  denuded  space  left  after  detachment  of  the  mesentery.  Although  the 
animal  partook  freely  of  food,  progressive  marasmus  set  in,  to  which  the  cat 
succumbed  eleven  days  after  the  operation.  Abdominal  wound  completely 
healed.  Union  of  implanted  ileum  with  colon  perfect.  No  peritonitis. 
Excluded  portion  empty.     Bowel  above  implantation  somewhat  dilated. 

Experiment  40.  Young,  but  full-grown  cat.  Physiological  exclusion  of 
two-thirds  of  the  small  intestines  and  the  entire  colon,  by  division  of  the 
small  intestines  at  the  junction  of  the  upper  with  the  middle  third.  Closure 
of  distal  end,  and  restoration  of  continuity  of  the  shortened  intestinal  tract 
by  making  a  jejuno-rectostomy.  The  implantation  was  made  into  the  upper 
portion  of  the  rectum  at  a  point  opposite  the  meso  rectum.  Previous  to 
section  and  suturing,  the  portion  of  bowel  to  be  excluded  was  emptied  of  its 
contents.  Animal  died  two  days  after  operation.  No  peritonitis.  Slight 
adhesions  between  the  serous  surfaces  of  rectum  and  implanted  jejunum; 
excluded  portion  empty. 


PHYSIOLOGICAL  EXCLUSION.  423 

Experiment  41.  The  entire  ileum  was  excluded,  in  a  cat,  by  dividing  the 
intestine  at  its  junction  with  the  jejunum,  closure  of  distal  end  and  making 
a  jejuno-colostomy  by  implantation  of  the  proximal  end  into  a  slit  of  the 
transverse  colon  at  a  point  opposite  the  meso-colon.  The  cat  remained  in 
good  condition  until  killed  fifteen  days  after  operation.  No  vomiting,  and 
movements  from  bowels  normal.  Abdominal  wound  completely  closed  ;  no 
peritonitis  ;  jejunum  at  point  of  implantation  firmly  united  ;  new  opening 
in  colon  the  size  of  the  lumen  of  the  ileum.  Excluded  portion  empty,  con- 
tracted and  anremic. 

Experiment  42.  Large  mastiff.  The  small  intestine  was  divided  six  and 
a  half  feet  above  the  ileo-caecal  region,  the  distal  end  closed,  and  the  proximal 
end  implanted  into  an  incision  of  the  transverse  colon  large  enough  to  receive 
it  at  a  point  opposite  the  meso-colon.  Suturing  was  done  exclusively  with 
fine  silk.  For  three  weeks  the  dog  appeared  quite  well,  ate  well,  and  the 
discharges  from  the  bowels  were  normal.  From  this  time  the  emaciation, 
which  commenced  soon  after  the  operation  was  done,  began  to  increase 
rapidly,  the  animal  began  to  refuse  food,  and  died  of  marasmus  thirty-two 
days  after  operation.  No  peritonitis.  Excluded  portion  empty,  and  reduced 
one-half  in  size  ;  the  coats  of  the  bowels  very  much  attenuated,  and  the 
vessels  hardly  half  the  normal  size.  Only  three  feet  and  five  inches  of  the 
small  intestine  remained  for  physiological  action.  New  opening  in  colon 
sufficiently  large  to  permit  the  introduction  of  the  index  finger  as  far  as  t  htj 
first  point.  On  slitting  open  the  colon,  the  point  of  juncture  with  the  jejunum 
upon  the  inner  surface  was  marked  by  a  slight  ridge  of  mucous  membrane, 
which  bore  a  faint  resemblance  to  the  ileo-csecal  valve. 

Remarks. — For  some  reason  which  I  am  unable  to  explain 
satisfactorily,  in  animals  where  the  same  length  of  intestine  was 
physiologically  excluded,  as  in  the  resection  experiments,  the 
appetite  never  became  so  voracious,  and  the  remaining  portion  of 
intestine  did  not  undergo  the  same  degree  of  compensatory  hyper- 
trophy as  in  the  excision  experiments.  Theoretically,  two  explana- 
tions might  be  advanced  :  first,  in  shortening  the  intestinal  canal 
by  resection,  an  extensive  vascular  district  is  cut  off  by  ligation  of 
the  mesentery,  and  it  is  only  reasonable  to  assume  that  the  circula- 
tion in  the  remaining  branches  of  the  mesenteric  artery  would  be 
increased,  and  •  consequently  the  functional  activity  of  the  organs 
supplied  by  them  augmented  ;  second,  in  cases  of  physiological 
exclusion  by  lateral  apposition,  it  is  possible  that  at  least  some  of 
the  fluid  contents  reached  the  excluded  portion  from  which  a  certain 
amount  might  still  have  become  absorbed.  The  exclusion  was  com- 
plete or  nearly  so,  hence  we  must  conclude  from  the  post  mortem 
appearances,  that  in  nearly  every  instance,  the  excluded  portion 
presented  an  atrophic,  contracted  condition,  and  was  only  sparingly 


424  EXPERIMENTAL  SURGERY. 

supplied  with  blood-vessels.  From  a  practical  standpoint  these 
experiments  teach  us  that  a  limited  portion  of  the  intestinal  canal 
can  be  permanently  excluded  from  the  processes  of  digestion  and 
absorption  in  proper  cases,  by  operative  measures  without  incurring 
any  risk  of  faecal  accumulation  in  the  excluded  part.  These  experi- 
ments demonstrate  also  that  physiological  exclusion  of  a  certain 
portion  of  the  intestinal  tract  is  a  less  dangerous  operation  than 
excision,  and  that  in  certain  cases  of  intestinal  obstruction,  where 
excision  has  been  heretofore  practiced,  it  can  be  resorted  to  as  a 
substitute  for  this  operation  in  cases  where  excision  is  impracticable, 
or  where  the  pathological  conditions  which  have  caused  the  obstruc- 
tion do  not  in  themselves  constitute  an  intrinsic  source  of  immediate 
or  remote  danger  to  life.  The  post-mortem  appearances  of  the 
specimens  of  these  experiments  tend  to  prove  that  as  long  as  any 
of  the  contents  of  the  intestines  reach  the  excluded  portion,  the 
peristaltic  or  anti -peristaltic  action  in  that  part  is  effective  in  forcing 
it  back  into  the  active  current  of  the  intestinal  circulation. 

III.    Circular  Enter  or  rhaphy. 

During  my  experimental  work  I  became  convinced  that  circular 
enterorrhaphy  as  it  is  now  commonly  performed  is  attended  by 
three  great  sources  of  danger:  1.  Perforation  at  the  junction  not 
covered  with  peritoneum  ;  2.  Length  of  time  required  in  perform- 
ing the  operation;     3.   The  number  of  sutures  required. 

To  obviate  the  danger  of  perforation  at  the  junction  of  the 
bowel  not  covered  by  serous  membrane,  I  resorted  to  peritoneal 
suturing  before  uniting  the  bowel,  by  drawing  the  peritoneum  over 
the  denuded  space  caused  by  the  limited  detachment  of  the  mesentery, 
by  a  fine  catgut  suture  applied  near  the  free  margin  of  the  bowel  as 
described  before.  This  requires  but  little  time,  and  secures  for  the 
whole  circumference  of  the  bowel  a  peritoneal  covering,  so  that  after 
the  bowel  has  been  sutured  the  great  rule  inaugurated  by  Lembert 
(serosa  against  serosa)  has  been  carried  out  to  perfection.  The 
results  showed  that  this  little  modification  of  the  ordinary  method 
of  suturing  yielded  more  satisfactory  results,  and  should  therefore 
be  adopted  in  all  cases  where  circular  enterorrhaphy  is  done  with 
Czerny-Lembert  or  Lembert's  sutures.  Time  plays  an  important 
part  in  determining  the  results  of  all  operations  requiring  abdom- 
inal section;  and  this  is  especially  true  in  all  operations  for  intestinal 


CIRCULAR  ENTERORRHAPHY.  425 

obstruction,  as  this  class  of  patients  is  usually  greatly  exhausted 
before  consent  to  an  operation  can  be  obtained.  With  a  patient 
exhausted  from  an  acute  attack  of  obstruction  of  the  bowels,  it 
becomes  exceedingly  important  to  consume  as  little  time  as  possible 
in  the  operation,  as  the  shock  incident  to  a  long  operation  may  itself 
determine  a  fatal  result.  Even  after  I  had  acquired  a  fair  degree 
of  manual  dexterity  in  suturing  the  bowel,  I  seldom  spent  less  than 
an  hour  in  making  a  circular  enterorrhaphy  with  a  double  row  of 
sutures.  In  opening  the  abdomen  for  intestinal  obstruction,  a  consid- 
erable length  of  time  is  usually  spent  in  finding  the  obstruction;  and 
when  this  is  found  and  the  patient  manifests  symptoms  of  collapse, 
a  radical  operation,  which  for  its  performance  requires  an  hour  or 
more,  is  often  abandoned  and  the  operation  finished  by  making  an 
artificial  anus,  which  at  the  present  time  must  be  looked  upon  as  a 
reproach  upon  good  surgery. 

The  last  objection  to  the  Czerny-Lembert  method  of  suturing 
requires  no  argument.  Any  surgeon  who  hastily  transfixes  the  bowel 
with  a  needle  from  thirty  to  forty  times  in  applying  the  Lembert 
suture  is  liable  to  perforate  the  whole  thickness  of  its  walls  once  or 
more;  and  if  silk  is  used  as  suturing  material,  the  puncture  may 
become  the  seat  of  a  perforation,  and  the  direct  cause  of  a  fatal  peri- 
tonitis. This  is  more  particularly  the  case  in  operating  on  the  bowel 
in  cases  of  intestinal  obstruction,  as  under  such  circumstances  the 
walls  of  the  bowel  have  become  greatly  attenuated  from  overdisten- 
tion,  and  consequently  more  liable  to  become  perforated  by  the 
needle.  But  the  use  of  so  many  sutures,  from  thirty  to  forty  as 
recommended,  brings  with  it  another  source  of  danger — gangrene 
of  the  inverted  margin  of  the  bowel.  The  second  row  of  sutures 
applied  in  such  close  proximity  must  materially  affect  the  blood 
supply  to  the  inverted  margin  of  the  bowel,  which  in  some  instances 
must  terminate  in  gangrene.  Such  a  result  is  the  more  likely  to 
ensue  as  the  inner  surface  of  the  bowel  is  exposed  to  all  dangers 
incident  to  infection  from  the  intestinal  canal;  in  other  words,  an 
aseptic  condition  for  one  side  of  the  woYmd  cannot  be  secured,  con- 
sequently the  gangrene  is  of  a  septic  character,  which  is  prone  to 
extend  beyond  the  primary  cause  which  produced  it. 

To  obviate  some  of  these  dangers  I  experimented  with  a  modifi- 
cation of  Jobert's  invagination  suture.  According  to  Madelung,  the 
ingenious  method  of  circular  suturing  devised  by  Jobert  was  practiced 


42(3  EXPERIMENTAL  SURGERY. 

only  in  four  cases,  and  two  of  the  patients  are  known  to  have  recov- 
ered. A  number  of  years  ago,  I  was  forced  to  resort  to  resection  of 
a  part  of  the  small  intestine  in  a  very  complicated  case  of  ovariotomy 
and  resorted  to  this  method,  and  although  the  patient  died  forty-eight 
hours  after  the  operation  from  causes  outside  of  this  complication, 
the  bowel  was  found  permeable  and  quite  firmly  united,  and  had  the 
patient  lived  I  have  no  doubt  the  result  of  the  resection  and  sutur- 
ing would  have  been  satisfactory.  In  Jobert's  method  the  invagina- 
tion sutures  must  be  looked  upon  as  a  source  of  danger,  as  they 
were  made  to  traverse  the  entire  thickness  of  the  wall  of  the  bowel, 
and  the  material  used  was  silk.  It  has  been  claimed  that  in  this 
method  the  invaginated  portion  of  the  bowel  becomes  gangrenous  as 
in  cases  of  invagination  from  pathological  causes.  This  claim  has 
arisen  from  a  theoretical,  and  not  from  an  experimental  standpoint. 
In  cases  of  invagination  the  intussusceptum  carries  with  it  the 
mesenteric  vessels  intact  in  the  form  of  an  arch,  which  by  constriction 
at  the  neck  of  the  intussuscipiens  is  prone  to  become  strangulated, 
an  event  which  is  followed  by  oedema  and  inflammatory  swelling  of 
the  invaginated  portion,  which  rapidly  tends  to  complete  venous 
stasis  and  gangrene.  In  circular  suturing  by  Jobert's  method  the 
intussusceptum  has  no  vascular  connection  with  the  intussuscipiens. 
The  vascular  arch  is  interrupted  and  consequently  the  danger  arising 
from  venous  obstruction  is  almost  completely  obviated.  My  experi- 
ments will  show  that  gangrene  of  the  invaginated  portion  as  a  rule 
does  not  occur.  My  modification  of  Jobert's  method  consists 
essentially  in  the  use  of  a  thin  elastic  rubber  ring  for  lining  the 
intussusceptum  to  prevent  ectropium  of  the  mucous  membrane,  to 
protect  the  mucous  membrane  of  the  bowel  against  injurious  pressure 
from  the  suture,  to  keep  the  lumen  of  the  bowel  patent  during  the 
inflammatory  stage,  and  to  assist  in  maintaining  coaptation  of  the 
serous  surfaces,  and  finally  the  substitution  of  catgut  for  silk  as 
invagination  sutures. 

My  method  of  proceeding  is  as  follows:  The  upper  end  of 
the  bowel  which  is  to  become  the  intussusceptum  is  lined  with  a 
soft  pliable  rubber  ring  made  of  a  rubber  band,  transformed  into 
a  ring  by  fastening  the  ends  together  with  two  catgut  sutures. 
This  ring  must  be  the  length  of  the  intussusceptum,  from  one-third 
to  half  an  inch;  the  lower  margin  is  stitched  by  a  continuous  catgut 
suture  to  the  lower  end  of  the  bowel  which  effectually  prevents  the 


CIRCULAR   ENTERORRHAPHY.  ±27 

bulging  of  the  raucous  membrane,  a  condition  which  is  always 
difficult  to  overcome  in  circular  suturing.  After  the  ring  is  fastened 
in  its  place  the  end  of  the  bowel  presents  a  tapering  appearance 
which  materially  facilitates  the  process  of  invagination.  Two  well 
prepared  fine  juniper  catgut  sutures  are  threaded  each  with  two 
needles.  The  needles  are  passed  from  within  outwards,  transfix- 
ing the  upper  portion  of  the  rubber  ring  and  the  entire  thickness 
of  the  wall  of  the  bowel  and  always  equidistant  from  each  other; 
the  first  suture  being  passed  in  such  a  manner  that  each  needle  is 
brought  out  a  short  distance  from  the  mesenteric  attachment,  and 
the  second  suture  on  the  opposite  convex  side  of  the  bowel.  During 
this  time  an  assistant  keeps  the  opposite  end  of  the  bowel  compressed 
to  prevent  contraction  and  bidging  of  the  mucous  membrane.  The 
needles  next  are  passed  through  the  peritoneal,  muscular  and  con- 
nective tissue  coats  at  corresponding  points  about  one- third  of  an 
inch  from  the  margins  of  the  opposite  end  of  the  bowel,  and  when 
all  the  needles  have  been  passed,  an  assistant  makes  equal  traction 
on  the  four  strings,  and  the  operator  assists  the  invagination  by 
turning  in  the  margins  of  the  lower  end  evenly  with  a  director,  and 
by  gently  pushing  the  rubber  ring  completely  into  the  intussus- 
cipiens.  The  invagination  accurately  made,  the  two  catgut  sutures 
are  tied  onl}»  with  sufficient  firmness  to  prevent  disinvagination 
should  violent  peristalsis  follow  the  operation.  This  is  their  only 
function. 

The  invagination  itself  effects  accurate,  almost  hermetical  seal- 
ing Of  the  visceral  wound.  The  intestinal  contents  pass  freely 
through  the  lumen  of  the  rubber  ring  from  above  downwards,  and 
escape  from  below  is  impossible,  as  the  free  end  of  the  intussuscipiens 
secures  accurate  valvular  closure.  After  a  few  days  the  rubber  ring 
becomes  detached,  and  by  giving  way  of  the  catgut  sutures  is  again 
transformed  into  a  flat  band,  which  readily  passes  off  with  the  dis- 
charges through  the  bowels.  The  invagination  sutures  of  catgut  are 
gradually  removed  by  substitution  on  the  part  of  the  tissues,  hence  the 
punctures  in  the  bowel  remain  closed  either  by  the  catgut  or  by  the 
products  of  local  tissue-proliferation;  and  thus  extravasation  is  pre- 
vented. In  my  first  experiments  I  used  three  invagination  sutures, 
but  found  by  experience  that  two  are  just  as  efficient  in  making  and 
retaining  the  invagination.  No  superficial  or  peritoneal  sutures  were 
used  in  any  of  the  cases,  solo  reliance  being  placed  upon  the  invagi- 


428  EXPERIMENTAL  SURGERY. 

nation  to  maintain  approximation  and  coaptation.  The  mesenteric 
attachment,  both  of  the  intussusceptum  and  intussuscipiens,  was 
separated  only  a  few  lines  to  enable  invagination  without  too  much 
narrowing  of  the  lumen  of  the  intussuscipiens. 

Experiment  43.  Dog,  weight  fifteen  pounds.  Three  invagination  sutures 
■were  used.  The  ileum  was  cut  completely  across  at  a  point  about  three  feet 
above  the  ileo-csecal  region.  Depth  of  invagination  one  inch.  For  two  days 
after  operation  a  slight  rise  in  temperature;  no  symptoms  of  obstruction 
during  the  whole  time.  Animal  in  good  condition  when  killed  two  weeks  after 
operation.  Omentum  adherent  at  point  of  operation  as  well  as  on  adjacent 
loop  of  intestine.  Union  between  intussusceptum  and  intussuscipiens  firm, 
no  signs  of  gangrene.  Narrowest  portion  of  lumen  of  bowel  was  large  enough 
to  pass  the  little  finger  to  second  joint.  An  enterolith  composed  of  fragments 
of  wood,  bone,  etc.,  in  the  centre  of  which  the  straight  rubber  band  which  had 
been  the  rubber  ring,  was  found  just  above  the  seat  of  operation.  No  disten- 
tion of  the  bowel  above  this  point.  Bowel  considerably  flexed  at  seat  of 
invagination,  this  condition  being  evidently  brought  about  by  inflammatory 
adhesions. 

Experiment  44.  Dog,  weight  twenty  pounds.  Section  of  bowel  and 
invagination  with  rubber  ring  the  same  as  in  the  foregoing  experiment.  In 
subsequent  history  no  mention  is  made  of  any  symptom  of  obstruction,  but 
for  the  last  few  weeks  it  was  noticed  that  the  dog  began  to  emaciate.  He  died 
suddenly  eighty-one  days  after  the  operation.  Diarrhoea  was  a  prominent 
symptom  toward  the  last.  No  adhesions  and  no  peritonitis.  An  enormous 
enterolith  composed  of  all  kinds  of  crude  material,  and  again  holding  in  its 
centre  the  rubber  band,  was  found  just  above  the  invagination.  Bowel  at  this 
place  considerably  dilated.  Intussusceptum  firmly  adherent,  a  false  passage 
admitting  the  tip  of  the  little  finger  had  been  made  on  one  side  between  it  and 
the  intussuscipiens.  Death  in  this  case  was  evidently  produced  by  the  entero- 
lith. In  this,  as  in  the  last  case,  the  invagination  was  made  at  least  an  inch 
in  length,  and  the  collection  around  the  detached  rubber  ring  of  the  crude, 
indigestible  material,  which  the  dog  must  have  eaten  in  large  quantities,  gave 
rise  to  the  enterolith.  The  wall  of  the  bowel  surrounding  the  foreign  body 
was  not  only  dilated,  but  also  greatly  thickened.  It  is  a  well  known  fact  that 
even  a  moderate  degree  of  stenosis  of  the  bowel  in  dogs  is  liable  to  give  rise 
to  the  formation  of  an  enterolith,  as  the  crude  material  which  these  animals 
swallow  becomes  arrested,  and  by  constant  accretions  of  the  same  kind  of 
material,  the  enterolith  forms  and  continues  to  increase  in  size,  until  its  pres- 
ence causes  catarrhal  inflammation  and  finally  intestinal  obstruction. 

It  is  quite  possible  that  the  lower  end  of  the  intussusceptum  became 
impermeable  during  the  inflammatory  stage,  and  that  the  false  passage  was 
formed  on  this  account  by  perforation  on  one  side  of  the  intussusceptum,  an 
accident  which  was  plainly  traceable  to  too  deep  invagination. 

Experiment  45.  Dog,  weight  forty  pounds.  This  experiment  is  interest- 
ing only  from  the  fact  that  it  shows  that  it  is  possible  to  make  a  mistake  in 


NOTHNAGEL'S   TEST.  429 

the  direction  of  the  invagination,  even  after  the  operation  has  determined 
with  accuracy  which  is  the  ascending  and  descending  end  of  the  gut,  and  to 
show  the  disastrous  consequences  which  must  necessarily  follow  such  a  techni- 
cal mistake.  The  invagination  was  made  in  the  usual  manner  with  rubber 
ring  and  three  catgut  sutures.  The  animal  appeared  to  be  quite  ill  the  day 
following  the  operation,  and  on  the  next  day  the  thermometer  showed  a  rise 
in  temperature  to  104.2 CF.  On  the  third  day  the  dog  died  with  well  marked 
symptoms  of  perforative  peritonitis.  Recent  peritonitis  with  some  aggluti- 
nations of  intestines.  Considerable  quantity  of  sero-sanguinolent  fluid  in  the 
peritoneal  cavity.  To  my  utter  astonishment,  I  found  that  an  ascending 
invagination  had  been  made.  Circular  gangrene  of  intussusceptum  and  com- 
plete separation  of  ends  was  found.  The  rubber  ring  remained  in  situ  still 
attached  to  the  intussuscipiens  by  the  catgut  sutures,  which  had  become  some- 
what softened.  The  invagination  had  decreased  considerably  by  the  traction 
caused  by  the  peristalsis  and  by  the  pressure  of  the  intestinal  contents  from 
above  the  obstruction,  and  the  extensive  gangrene  of  the  bowel  was  undoubt- 
edly determined  to  a  great  extent  by  these  causes. 

Experiment  46.  This  experiment  illustrates  another  source  of  danger 
due  to  faulty  technique.  Medium-sized  dog.  Circular  enterorrhaphy  was  done 
with  the  rubber  ring  two  feet  above  the  ileo-csecal  valve.  In  making  the  invagi- 
nation it  was  noticed  that  the  ring  was  too  large,  as  it  was  seen  that  it  caused 
too  much  pressure.  Thinking  that  the  parts  might  adapt  themselves  to  this 
pressure,  the  bowel  was  replaced  and  the  abdominal  wound  closed.  The  dog 
died  thirty-six  hours  after  the  operation.  Abdominal  wound  not  united; 
omentum  and  intestines  adherent  to  each  other,  and  at  point  of  operation. 
The  circumscribed  gangrene  of  the  intussuscipiens  was  evidently  entirely  due 
to  pressure  on  the  part  of  the  rubber  ring.  The  intussuscipiens  was  much 
swollen,  a  condition  which  materially  aggravated  the  pressure  caused  by  the 
rubber  ring.  With  the  following  experiment  two  new  departures  were  inaugu- 
rated, viz.:  Instead  of  three  invagination  sutures  only  two  were  used,  a  change 
which  still  further  shortened  the  time  for  performing  the  operation,  and  Noth 
nagel's  test  was  employed  to  determine  the  direction  in  which  the  invagination 
should  be  done.  In  all  of  the  remaining  experiments  of  circular  enterorrhaphy 
which  were  made,  only  two  catgut  sutures  were  used.  Until  this  time  it  was 
necessary  to  find  one  of  the  extremities  of  the  small  intestines  for  the  pur- 
pose of  determining  which  was  the  afferent  and  which  the  efferent  end  of  the 
tube,  so  as  to  make  the  invagination  in  the  right  direction;  a  procedure  which 
often  required  considerable  time,  and  brought  additional  risk  by  increasing 
the  shock  of  the  operation  and  the  danger  of  traumatic  infection. 

i.     Nothnagel's  Test. 

In  experimenting  upon  animals  for  the  purpose  of  studying  the 
functions  of  the  intestinal  canal  in  health  and  disease,  Nothnagel 
made  the  discovery  that  when  the  salts  of  potash  are  brought  in 
contact  with  the  serous  surface  of  the  bowel,  circular  constriction 


430  EXPERIMENTAL  SURGERY. 

takes  place,  and  when  the  peritoneal  surface  is  touched  with  a 
crystal  of  common  salt,  ascending  peristalsis  is  produced.  The  sodic 
chloride  test  I  applied  in  sixteen  cases,  and  found  Nothnagel's 
observations  corroborated  in  fifteen  cases,  by  subsequent  anatomical 
examination.  In  the  remaining  case  where  a  wrong  conclusion  was 
drawn,  the  error  might  have  been  due  to  a  faulty  observation,  or  else 
the  observation  was  not  continued  for  a  sufficient  length  of  time.  If, 
in  the  human  subject,  these  observations  could  be  verified,  it  would 
be  of  great  practical  importance  to  surgeons  in  operations  on  the 
intestinal  canal  whenever  it  becomes  necessary  to  determine  which 
is  the  ascending  or  descending  part  of  the  bowel. 

Experiment  47.  Dog,  weight  thirty  pounds.  Circular  section  of  ileum 
and  immediate  enterorrhaphy  by  invagination  with  rubber  ring  and  two 
catgut  sutures.  Intussusceptum  invaginated  not  more  that  a  quarter  of  an 
inch.  A  few  days  after  the  operation  stools  mixed  with  blood,  no  other 
unfavorable  symptoms.  Animal  killed  fourteen  days  after  operation.  Wound 
united  firmly.  A  number  of  omental  and  intestinal  adhesions.  A  small 
abscess  in  mesentery  at  point  of  operation.  No  obstruction  of  any  kind.  On 
opening  the  bowel  the  walls  at  site  of  operation  were  very  thick,  correspond- 
ing to  the  three  intestinal  coats,  which  had  become  considerably  attenuated. 
The  inner  surface  showed  the  point  of  junction  of  the  intussusceptum  with  the 
intussuscipiens  in  the  shape  of  a  circular  ring  of  mucous  membrane.  The 
most  contracted  portion  was  large  enough  to  admit  the  little  finger. 

Experiment  48.  Dog,  weight  fifteen  pounds.  Section  of  ileum  and 
circular  enterorrhaphy  with  rubber  ring  and  two  catgut  sutures.  Depth  of 
invagination  one-third  of  an  inch.  No  unfavorable  symptoms  after  operation. 
Animal  killed  after  seven  days.  Wound  completely  united.  Firm  union  of 
visceral  wound;  no  gangrene  of  intussusceptum.  Rubber  ring  retained  in  situ 
by  catgut  sutures,  which  were  easily  torn.  Upper  end  of  rubber  ring  matted 
with  hair.  No  obstruction.  Lumen  of  bowel  somewhat  contracted  by  a 
circular  ridge  of  mucous  membrane,  which  indicated  the  junction  of  the  two 
invaginated  ends  of  the  bowel. 

2.     Transplantation  of  Omental  Flap. 

In  almost  all  post-mortem  examinations  of  specimens  from  oper- 
ations on  the  intestines,  I  observed  that  the  omemtum  was  adherent 
over  a  greater  or  less  surface  at  the  seat  of  suturing.  I  also  observed 
that  perforations  never  occurred  where  this  additional  protection 
to  the  peritoneal  cavity  had  formed.  To  anticipate  nature  in 
protecting  the  peritoneal  cavity  in  this  manner,  I  commenced  to 
transplant  an  omental  flap  about  an  inch  in  width  and  sufficiently 
long  to  reach  around  the  bowel,  over  the  neck  of  the  intussuscipiens, 


TRANSPLANTATION   OF  OMENTAL  FLAP.  431 

where  it  was  fastened  on  the  mesenteric  side  by  two  catgut  sutures. 
The  flap  was  taken  either  from  the  margin  of  the  omentum  or  from 
its  middle,  care  being  taken  to  take  some  portions  supplied  with  a 
vessel  of  considerable  size.  Its  base  was  left  attached  to  the 
omentum;  all  bleeding  points  were  carefully  tied  with  catgut  liga- 
tures. The  two  catgut  stitches  used  for  its  fixation  were  passed  twice 
through  the  flap,  its  base  and  free  end  and  the  mesentery,  in  such  a 
way  that  when  tied  the  direction  of  the  suture  corresponded  to  the 
course  of  the  mesenteric  vessel,  so  that  after  tying  they  would  not 
interfere  with  the  vascular  supply  of  the  bowel.  When  the  flap  was 
taken  from  the  middle  of  the  omentum,  the  lateral  halves  were  united 
with  one  or  two  catgut  sutures  before  closing  the  abdominal  wound. 

Experiment  49.  Dog,  weight  forty  pounds.  Ileum  divided  eighteen 
inches  above  ileo-caecal  region,  and  the  ends  united  by  invagination  with 
rubber  ring,  and  two  catgut  sutures.  Transplantation  of  omental  flap  one 
inch  in  width  around  the  whole  circumference  of  the  bowel  over  neck  of  intus- 
suscipiens,  fixation  with  two  catgut  sutures  on  mesenteric  side.  Invagination 
one-third  of  an  inch  in  depth.  Animal  killed  two  weeks  after  operation. 
Abdominal  wound  perfectly  healed.  Omental  flap  firmly  adherent  to  bowel 
over  neck  of  intussuscipiens.  Bowel  at  seat  of  operation  much  thickened; 
rubber  ring  gone;  lumen  of  bowel  at  its  most  contracted  point  large  enough 
for  the  passage  of  the  little  finger. 

Experiment  50.  Dog,  weight  twenty  pounds.  Complete  division  of  ileum 
and  immediate  union  of  divided  ends  by  invagination  with  rubber  ring  and 
two  catgut  sutures.  Transplantation  of  omental  flap  two  inches  in  width 
over  the  neck  of  the  intussuscipiens.  On  third  day  stools  mixed  with  blood. 
Died  on  the  fifth  day.  Wound  not  united;  omental  flap  firmly  adherent  except 
at  a  small  point  on  the  mesenteric  side  where  a  minute  perforation  had  taken 
place  from  circumscribed  gangrene  of  the  intussusceptum.  Rubber  ring  only 
loosely  held  by  one  of  the  sutures.  Lumen  in  invaginated  portion  quite 
narrow,  but  permeable. 

Experiment  51.  Dog,  weight  fifteen  pounds.  Complete  section  of  ileum 
and  union  of  divided  ends  by  invagination.  The  rubber  ring  was  only  one- 
third  of  an  inch  wide,  while  formerly  none  were  used  less  than  half  an  inch 
in  width.  Neck  of  intussuscipiens  protected  by  an  omental  flap  two  inches 
wide.  The  dog  remained  perfectly  well,  and  was  killed  twenty-five  days  after 
operation.  Abdominal  wound  completely  healed,  covered  on  the  inner  side 
by  adherent  omentum.  Rubber  ring  gone.  Lumen  of  bowel  at  most  con- 
tracted point  readily  admits  the  little  finger.  No  signs  of  obstruction. 
Omental  flap  adherent  throughout. 

Experiment  52.  Dog,  weight  twenty-two  pounds.  Division  of  ileum  and 
suturing  in  usual  manner  by  invagination  with  rubber  rin^  and  two  catgut 
sutures;  transplantation  of  omental  flap.  The  dog  remained  perfectly  well 
and  was  killed  twenty-three  days  after  operation.     A  number  of  intestinal 


-J-32  EXPERIMENTAL  SURGERY. 

adhesions  had  produced  several  flexions.  Point  of  operation  four  feet  above  . 
the  ileo-caecal  region.  Omental  flap  firmly  adherent  to  bowel  throughout. 
Rubber  ring  gone.  Lumen  of  bowel  in  invaginated  portion  quite  large. 
Thb  invaginated  portion  so  atrophic  and  retracted  that  it  appeared  in  the 
shape  of  a  firm  ring  and  was  indicated  in  the  interior  by  a  circular  promi- 
nence of  the  mucous  membrane.     No  evidence  of   obstruction. 

Experiment  53.  Dog,  weight  fifteen  pounds.  Complete  division  of  the 
ileum  and  reunion  of  ends  by  invagination.  Transplantation  of  omental 
flap  two  inches  in  width  over  neck  of  intussuscipiens,  two  catgut  fixation 
sutures.  Second  day  after  operation  stools  bloody.  After  this  time  all  func- 
tions normal.  Animal  killed  forty-four  days  after  operation.  Point  of  opera- 
tion four  feet  below  the  pylorus.  The  invaginated  portion  atrophied  and 
retracted  to  such  an  extent  that  the  bowel  at  this  point  only  presented  a  thick- 
ened ring  with  its  lumen  but  slightly  narrowed  by  a  circular  ridge  of  mucous 
membrane.      Omental  flap  firmly  adherent  all  around  and  greatly  atrophied. 

Remarks. — In  circular  enterorrhaphy,  as  in  cases  of  intestinal 
wounds  of  any  kind,  the  ideal  of  any  operation  should  be  to  bring 
in  continuous,  uninterrupted  apposition  a  large  surface  of  serous 
membrane,  without,  at  the  same  time,  interfering  with  the  vascular 
supply  of  the  parts  which  it  is  intended  to  bring  together  for  perma- 
nent union  by  cicatrization.  If  in  employing  the  Czerny-Lembert 
sutures  more  than  a  few  lines  of  the  margins  of  the  bowel  are 
inverted  and  included  between  the  two  rows  of  sutures,  there  is 
great  danger  of  causing  primary  traumatic  stenosis  by  the  project- 
ing circular  ring  in  the  lumen  of  the  bowel.  The  narrowing  of  the 
lumen  of  the  bowel  must  be  as  great,  if  not  greater,  than  after 
invagination.  That  the  second  row  of  sutures  has  often  been  the 
cause  of  gangrene  of  the  inverted  margin  of  the  bowel  would  not 
be  difficult  to  prove  by  many  post-mortem  records  and  specimens. 
By  invaginating  to  the  depth  of  a  quarter  or  third  of  an  inch,  accu- 
rate coaptation  is  secured  of  the  corresponding  serous  surfaces 
between  the  intussusceptum  and  intussuscipiens,  which  is  made 
more  secure  and  effective  by  the  elastic  pressure  exerted  by  the  rub- 
ber ring.  This  method  of  coaptation  furnishes  a  large  peritoneal 
surface  of  peritoneum  for  immediate  union  by  cicatrization. 

With  perhaps  one  exception,  all  of  my  experiments  have  shown 
that  when  catgut  was  used  for  invagination  sutures  none  of  the  fail- 
ures were  attributable  to  their  presence.  On  the  inner  side  of  the 
bowel  the  rubber  ring  is  drawn  against  the  puncture,  and  would  thus 
furnish  a  mechanical  protection  against  the  escape  of  fluids  along 
these  minute  canals  ;  besides,  the  swelling  of  the  catgut  where  it 


CIRCULAR   ENTERORRHAPHY.  433 

becomes  softened  by  the  fluids  of  the  tissues,  would  most  effectually 
plug  the  punctures  until  a  permanent  plug  is  furnished  by  the  gran- 
ulations, which  in  time  completely  remove  the  catgut  by  substitution 
and  close  the  punctures  permanently  by  a  minute  cicatrix.  One  great 
advantage  of  the  rubber  ring  consists  in  its  furnishing  absolute 
protection  to  the  bowel  against  pressure  by  the  invagination  sutures 
during  the  invagination,  and  subsequent  traction  from  peristaltic 
contraction  should  the  latter  cause  tension  of  the  sutures,  an  occur- 
rence which  is  not  likely  to  arise  if  the  invagination  has  been 
properly  done.  A  circular  enterorrhaphy  as  described  above  can  be 
done  in  fifteen  minutes,  which  certainly  compares  very  favorably 
with  any  other  procedure,  as  far  as  time  is  concerned.  In  the 
description  of  a  number  of  the  specimens,  it  has  been  distinctly 
stated  that  the  injurious  results  followed  the  stenosis  caused  by  the 
invagination,  and  this  might  be  urged  as  an  argument  against  the 
safety  and  applicability  of  the  operation. 

As  compared  with  the  human  subject  the  dog  is  an  unfavorable 
animal  for  circular  enterorrhaphy  by  invagination.  In  the  first  place, 
the  walls  of  the  bowel  are  much  thicker  in  proportion  to  its  lumen 
than  in  man,  a  condition  which  of  necessity  seriously  affects  the 
lumen  of  the  intussusceptum.  Again,  the  dogs  were  allowed  to  eat 
what  they  desired  before  and  after  the  operation,  and  the  quantity 
was  not  limited;  consequently  a  great  deal  of  indigestible  substances, 
often  of  the  coarsest  kind,  as  straw,  fragments  of  wood,  or  bone, 
hair,  etc.,  found  their  way  into  the  intestinal  canal,  and  in  a  number 
of  cases  were  arrested  at  the  point  of  narrowing  in  the  bowel,  where 
they  gave  rise  to  the  formation  of  an  enterolith.  In  one  instance 
death  resulted  clearly  from  intestinal  obstruction  from  such  a  cause. 
In  men  the  coats  of  the  bowel  being  thinner,  and  the  lumen  corre- 
spondingly larger,  invagination  is  done  with  greater  ease,  and  the 
danger  from  stenosis  could  hardly  come  into  question,  as  the  fluid 
contents  of  the  small  intestines  would  pass  readily  through  the 
rubber  tube.  Some  of  the  older  specimens  prove  that  the  traumatic 
stenosis  caused  by  the  invagination  gradually  diminishes  by  atrophy 
of  the  invaginated  portions,  which  finally  only  appear  as  a  promi- 
nent ridge  of  mucous  membrane  on  the  inner  surface  of  the  bowel, 
the  remaining  coats  having  completely  or  nearly  disappeared  by 
retrograde  metamorphosis  and  absorption.  In  the  healing  of  all 
wounds  one  important  condition  for  an  ideal  result  is  rest.     The 


434  EXPERIMENTAL   SURGERY. 

rubber  ring  in  the  intussusceptuin  secures  this  important  condition 
for  the  invaginated  portion,  as  the  elastic  pressure  must  overcome 
peristaltic  action  and  secure  for  this  segment  of  the  bowel,  as  near 
as  possible,  absolute  physiological  rest.  The  danger  of  stenosis 
after  invagination  is  greatest  as  soon  as  inflammatory  swelling 
makes  its  appearance,  a  day  or  two  after  the  operation,  and  the  rub- 
ber ring  is  again  in  the  right  place  to  prevent  any  undue  swelling 
by  affording  a  gentle  support  for  the  invaginated  portion,  which 
cannot  fail  in  preventing  undue  venous  engorgement  and  oedema, 
which  would  otherwise  follow  the  invagination.  It  serves  both  the 
purpose  of  a  splint  and  an  elastic  bandage.  After  union  of  the 
bowel  by  invagination  with  a  rubber  ring  peritoneal  sutures  are 
superfluous,  as  the  invagination  itself  most  effectually  prevents  any 
escape  of  intestinal  contents  by  the  valvular  action  of  the  invaginated 
portion ;  at  the  same  time  the  serous  surfaces  are  kept  in  perma- 
nent and  uninterrupted  contact  by  the  elastic  pressure  on  the  part 
of  the  rubber  ring. 

Although  the  experiments  have  demonstrated  the  safety  of  the 
catgut  invagination  sutures  in  operating  upon  dogs,  the  same 
innocuity  might  not  attend  operations  after  intestinal  resections  for 
obstruction,  as  in  such  cases  the  coats  of  the  bowel  are  almost  with- 
out exception  very  much  attenuated,  and  consequently  the  danger 
of  extravasation  along  the  needle  punctures  would  be  increased. 
Very  recent  trials  have  satisfied  me  that  invagination  after  circular 
resection  can  be  done  with  the  rubber  ring  with  facility,  and  probably 
greater  safety,  by  dispensing  with  the  invagination  sutures  and 
adopting  the  following  plan:  The  lower  end  of  the  intussusceptum 
is  lined  with  a  soft  rubber  ring  about  one-quarter  to  one-third  of  an 
inch  in  width,  and  its  lumen  of  sufficient  size  to  afford  free  transit 
to  the  intestinal  contents.  The  lower  margin  of  the  ring  is  stitched 
•  to  the  end  of  the  intussusceptum  by  a  continued  fine  catgut  suture. 
The  ends  of  the  bowel  are  now  brought  in  contact  and  fastened 
together  with  four  catgut  sutures  which  are  placed  equidistant  from 
each  other.  Invagination  is  now  made  by  gently  pushing  the  ends 
of  the  bowel  in  opposite  directions,  being  careful  to  push  the  ring 
sufficiently  deep  so  that  its  upper  margin  is  grasped  by  the  neck  of 
the  intussuscipiens.  A  few  superficial  sutures  are  applied  simply 
for  the  purpose  of  preventing  disinvagination  ;  the  four  catgut 
sutures  act  as  invagination  sutures,  and  at  the  same  time  prevent 


INTESTINAL   ANASTOMOSIS.  435 

ectropiuin  of  the  mucous  ineinbrane  of  the  lower  end  of  the  bowel 
during  and  after  invagination.  With  proper  facilities  and  good 
assistance,  a  circular  enterorrhaphy  can  be  made  in  this  manner 
without  using  invagination  sutures,  in  ten  minutes;  and  by  using  not 
more  than  four  retention  sutures,  the  blood  supply  to  the  inverted 
portions  is  not  impaired,  and  at  the  same  time  the  two  ends  of  the 
bowel  have  been  joined  together  by  a  large  surface  of  peritoneum, 
which  is  held  in  accurate  contact  for  rapid  union  by  granulation 
and  cicatrization. 

The  advantages  that  are  derived  from  covering  a  sutured  intes- 
tinal wound  by  an  omental  flap  are  self-evident.  The  procedure  is 
simply  an  imitation  of  nature's  process  in  protecting  the  perito- 
neal cavity  against  perforation,  and  in  hastening  the  healing  of  the 
visceral  wound.  An  adherent  omentum  secures  rest  for  the  part  to 
which  it  has  become  attached.  As  the  omental  flap  becomes  firmly 
adherent  before  definitive  healing  of  the  visceral  wound  has  taken 
place,  it  furnishes  additional  protection,  and  in  the  event  of  a  small 
perforation  it  guards  against  perforative  peritonitis  by  mechanically 
preventing  the  entrance  of  pus  into  the  peritoneal  cavity.  Should 
pus  reach  the  omental  flap  after  it  has  become  firmly  adherent  it  is 
not  very  probable  that  perforation  would  take  place  through  the 
two  layers  of  peritoneum  furnished  by  the  adherent  omental  flap,  and 
the  subsequent  healing  of  the  perforation  of  the  bowel  would  be 
most  likely  to  take  place.  I  shall  again  refer  to  this  subject  under 
the  head  of  ''Omental  Grafting." 

IX.    Intestinal   Anastomosis. 

By  an  intestinal  anastomosis  we  understand  a  condition  of  the 
intestinal  canal  where  on  account  of  an  obstruction  or  complete 
occlusion,  the  intestinal  contents  are  directed  into  a  segment  of  the 
bowel  below  the  seat  of  obstruction  or  occlusion,  through  a  fistulous 
opening  between  the  bowel  above  and  below  the  seat  of  partial  or 
complete  occlusion.  The  idea  of  establishing  such  a  commxanication 
between  the  bowel  above  and  below  the  seat  of  obstruction  originated 
with  Maisonneuve,  who,  without  testing  the  new  procedure  first  on 
animals,  operated  on  two  cases,  but  as  the  result  in  each  case  was 
fatal,  he  seems  to  have  become  discouraged  and  abandoned  the 
operation,  and  never  published  the  communication  on  this  subject 
which  he  had  in  preparation.      In  the  Surgical  Society  of  Paris,  his 


436  EXPERIMENTAL  SURGERY. 

proposition  met  with  violent  opposition  fftun  his  contemporaries,  who 
argued  that  the  excluded  portion  of  the  intestine  would  become  the 
seat  of  faecal  accumulation,  which,  even  if  the  operation  were  a 
success,  would  subsequently  destroy  the  life  of  the  patient.  The 
subject  was  revived  in  1863  by  Hacken,  who  under  the  directions  of 
Adelmann  made  some  experiments  on  dogs.  For  a  long  time  the 
operation  was  completely  forgotten  until  E.  Hahn,  of  Berlin,  very 
recently  alluded  to  it  again  in  commenting  on  his  two  cases  of 
excision  of  the  colon  where  circular  enterorrhaphy  could  not  be 
performed,  and  where  an  artificial  anus  was  established.  Both 
patients  recovered  from  the  operation,  but  all  attempts  to  close  the 
preternatural  opening  proved  futile. 

The  results  of  my  experiments  have  shown  conclusively  that  the 
fear  of  accumulation  of  faeces  in  the  excluded  portion  of  the  intestine, 
that  is,  the  intervening  portion  containing  the  seat  of  obstruction 
and  extending  on  each  side  as  far  as  the  new  opening  by  which  the 
anastomosis  has  been  established,  is  unfounded.  If  this  objection 
can  be  laid  aside,  it  becomes  evident  that  the  operation  of  establish- 
ing intestinal  anastomosis  has  a  great  future,  and  will  soon  become 
an  established  procedure  in  the  treatment  of  intestinal  obstruction, 
and  as  a  substitute  for  circular  suturing  in  some  forms  of  injuries  of 
the  intestines,  which  require  excision.  When  I  first  made  my  experi- 
ments for  establishing  intestinal  anastomosis,  I  made  the  operation 
by  making  an  incision  an  inch  and  a  half  to  two  inches  in  length 
through  the  convex  surface  of  each  bowel,  and  sutured  the  wounds 
together  by  Czerny-Lembert  sutures  the  same  as  in  making  a  circular 
enterorrhaphy.  The  results  soon  showed  that  the  operation  was 
attended  by  the  same  dangers  as  suturing  after  circular  resection, 
that  is,  gangrene  of  the  margins  of  the  bowel,  and  perforation. 

Dr.  M.  E.  Connel,  Superintendent  of  the  Milwaukee  County 
Hospital,  suggested  the  use  of  perforated  plates  for  making  the 
lateral  apposition,  in  place  of  suturing.  A  few  crude  experiments 
were  made  with  perforated  discs  of  lead,  wood,  gutta-percha,  and 
leather,  and  the  results  soon  satisfied  us  of  the  expediency  and  greater 
safety  of  uniting  the  intestines  in  this  manner.  Although  the  first 
experiments  were  very  imperfect,  and  faulty  in  technique,  almost 
every  animal  recovered.  In  the  first  experiments  no  needles  were 
used.  Around  the  oval  perforation  four  catgut  or  silk  sutures  were 
tied;  a  slit  was  made  in  the  bowel  on  the  convex  side  parallel  with  its 


DIRECTIONS  FOR   PREPARING   BONE  PLATES.  437 

axis  and  large  enough  to  permit  the  passage  of  a  plate  about  an  inch 
in  width  and  about  two  and  a  half  inches  in  length.  After  making 
the  incision,  and  introducing  the  plate  above  and  below  the  seat  of 
obstruction,  the  two  wounds  were  brought  into  apposition,  and  the 
corresponding  strings  tied  together  with  sufficient  firmness  to  bring 
the  flattened  surfaces  into  accurate  coaptation.  The  threads  were 
cut  short  and  the  ends  pushed  inward  out  of  sight.  Experience 
showed  that  although  the  apposition  was  good,  a  tendency  was 
observed  on  the  part  of  the  margins  of  the  wound  to  evert  on  account 
of  the  bulging  of  the  mucous  membrane.  I  consequently  modified 
the  operation  by  arming  the  lateral  threads  with  a  needle  with  which 
the  margin  of  the  incision  about  the  middle  of  the  wound  was  trans- 
fixed. This  proved  a  step  in  the  right  direction,  as  the  lateral 
sutures  completely  prevented  eversions  of  the  margins  of  the  wound, 
at  the  same  time  they  fixed  the  plates  in  their  position,  and  lastly,  at 
once  transformed  the  longitudinal  slit  into  an  oval  foramen  of  suffi- 
cient size  for  the  free  passage  of  intestinal  contents.  After  many 
trials  with  different  kinds  of  materials  for  the  plates,  I  came  to  the 
conclusion  that  decalcified  or  partially  decalcified  bone  plates,  pre- 
served after  the  decalcification  in  pure  alcohol,  served  the  best 
purpose. 

Directions  for  Preparing-  Bone  Plates. 

The  compact  layer  of  an  ox's  femur  or  tibia  is  cut  with  a  fine 
saw  into  oval  plates,  one-fourth  of  an  inch  in  thickness,  two  and  one- 
half  to  three  inches  in  length,  and  an  inch  in  width.  The  plates  are 
then  decalcified  in  a  ten  per  cent,  solution  of  hydrochloric  acid, 
changed  every  twenty- four  hours  until  they  have  become  sufficiently 
soft  so  that  they  can  be  bent  in  any  direction  without  fracturing. 
After  decalcification  they  are  washed  In  letting  water  flow  over  them 
from  three  to  six  hours  so  as  to  remove  the  acid.  The  plates  are  then 
covered  with  porous  paper  and  compressed  between  two  pieces  of 
tin  until  they  are  perfectly  dry.  If  during  the  process  of  drying  the 
plates  are  not  compressed  between  two  smooth  surfaces  the\  heroine 
distorted  by  warping.  The  hardened  plates  are  next  drilled  several 
times  in  a  straight  line  in  the  centre,  and  the  openings  enlarged 
and  connected  with  a  file,  until  the  perforation  is  five-eighths  of 
an  inch  in  length  and  aboul  one  eighth  to  one-sixth  of  an  inch  in 
width.      The   sharp    margins   of   the   plate   and    perforations   are 


438  EXPERIMENTAL   SURGERY. 

removed  with  a  file.  With  a  fine  drill  the  four  perforations  for  the 
sutures  are  made  near  the  margin  of  the  oblong  perforation,  one  at 
each  end  and  one  at  each  side.  For  preservation  the  plates  are  kept 
in  absolute  alcohol.  When  the  plates  are  to  be  used  they  are 
washed  in  a  two  per  cent,  carbolic  acid  solution,  and  the  threads  or 
sutures  attached  by  threading  two  fine  sewing  needles,  each  with  a 
piece  of  aseptic  silk,  twenty-four  inches  in  length,  which  are  tied 
together.  The  threads  are  then  fastened  to  the  surface  of  the  plate 
by  another  thread  passing  through  the  perforations  in  the  shape  of 
a  loop  and  fastened  at  the  back. 

Instead  of  describing  the  experiments  in  their  chronological 
order,  I  will  enumerate  them  according  to  the  part  of  the  intes- 
tine operated  upon,  commencing  with  the  upper  portion  of  the 
intestinal  tract. 

i.     Gastro-Enterostomy. 

As  gastro- enterostomy  is  an  operation  which  establishes  an 
anastomosis  between  the  stomach  and  the  upper  portion  of  the 
intestinal  canal,  with  exclusion  of  the  duodenum,  and  sometimes  a 
portion  of  the  jejunum,  and  is  performed  in  cases  of  obstruction  in 
the  pylorus  or  duodenum,  it  comes  within  the  legitimate  sphere  of 
this  article.  Gastro -enterostomy,  as  heretofore  described  and  per- 
formed, is  an  operation  attended  by  many  difficulties,  and  requires 
even  in  the  hands  of  an  expert  an  hour  or  more  for  its  execution. 
As  this  operation  is  only  done  in  cases  greatly  debilitated  by  disease 
and  long  suffering,  anything  which  will  simplify  the  technique  and 
shorten  the  time  must  be  looked  upon  as  an  improvement.  An 
operation  that  can  be  done  in  ten  minutes  instead  of  an  hour  or  two, 
and  which  furnishes  even  better  conditions  for  the  healing  of  the 
visceral  wounds,  must  take  the  place  of  the  more  complicated  pro- 
cedures which  so  far  have  only  been  practiced  in  the  hands  of  the 
most  experienced  surgeons. 

Eperiment  54.  Dog,  weight  twenty-five  pounds.  Incision  made  through 
linea  alba  from  xiphoid  cartilage  to  near  umbilicus.  Omentum  pushed  to  one 
side,  and  the  stomach  drawn  forward  into  the  wound;  near  the  middle  of  its 
anterior  surface  a  longitudinal  incision  was  made,  two  inches  in  length,  and  a 
perforated  gutta-percha  plate,  to  which  four  medium-sized  juniper  catgut 
sutures  were  attached,  was  introduced.  The  lateral  sutures,  armed  with 
needles,  were  passed  through  the  entire  thickness  of  the  walls  of  the  stomach, 
half  way  between  the  angles  of  the  wound.     A  similar  incision  was  made  into 


GASTRO-EXTEROSTOMY.  439 

the  intestine  at  the  junction  of  the  duodenum  with  the  jejunum;  the  same 
kind  of  plate  introduced,  and  the  margins  of  the  wound  punctured  by  t  Ki- 
lateral  armed  sutures,  when  the  two  wounds  were  brought  vis-a-vis  and  the 
corresponding  sutures  tied.  In  tying  the  sutures,  the  lower  lateral  suture  was 
tied  first  and  the  threads  cut  short;  next  the  sutures  corresponding  to  each 
angle  of  the  wound  were  tied,  and  lastly  the  upper  lateral.  The  serous  surfaces 
of  the  stomach  and  intestine  over  an  area  corresponding  to  the  size  of  the 
plates  were  brought  into  accurate  permanent  contact  by  the  tying  of 
the  sutures.  The  stomach  was  replaced  and  the  abdominal  wound  closed. 
The  animal  was  allowed  to  eat  immediately  after  the  operation,  manifested 
no  signs  of  illness  or  pain,  and  was  killed  seven  days  after  operation. 
Abdominal  wound  healed.  Omentum  adherent  to  its  inner  surface.  Union 
between  stomach  and  bowel  firm  over  the  entire  surface  of  approximation. 
Plates  detached,  the  one  in  the  bowel  had  passed,  while  the  other  was  found 
loose  in  the  stomach.  The  new  opening  large  enough  to  admit  the  index 
finger. 

Experiment  55.  Dog,  weight  fifty  pounds.  The  operation  was  performed 
in  the  same  manner  as  in  the  previous  experiment,  but  great  difficulty  was 
experienced  in  bringing  the  stomach  forward,  as  this  organ  was  distended  to 
its  utmost  with  an  enormous  quantity  of  solid  food.  Evacuation  was  effected 
through  the  incision,  aided  by  attempts  of  the  animal  to  vomit,  the  violent 
contractions  of  the-stomach  forcing  the  food  toward  the  opening,  from  which 
it  was  removed  with  fingers  and  spoon.  After  the  stomach  was  emptied  it  was 
washed  out  with  warm  water.  For  the  stomach  a  bone  plate,  only  partially 
decalcified,  was  used,  while  the  approximation  plate  in  the  bowel  was  fully 
decalcified.  The  four  approximation  sutures  were  of  catgut.  Several  portions 
of  omentum,  which  were  soiled  during  the  emptying  of  the  stomach,  were 
excised.  The  abdominal  cavity  was  thoroughly  irrigated  with  warm  water 
before  the  wound  was  closed.  The  animal  died  the  next  day,  and  on  opening 
the  abdomen  it  was  ascertained  that  the  immediate  cause  of  death  was 
hiemorrhage,  as  the  peritoneal  cavity  was  filled  with  blood.  .  The  bleeding 
undoubtedly  took  place  from  the  omentum,  by  slipping  or  loosening  of  one 
of  the  catgut  ligatures. 

Experiment  56.  Medium-sized  dog.  t  Operation  performed  in  the  same 
manner  with  decalcified  bone  plates  and  catgut  sutures.  The  first  two  days 
the  animal  had  several  attacks  of  vomiting,  subsequently  showed  no  signs  of 
suffering.  Appetite  good  and  stools  regular.  Killed  Ihirty-four  days  after 
operation.  Omentum  adherent  to  inner  surface  of  abdominal  wound.  At 
point  of  operation  stomach  was  contracted,  so  that  the  organ  presented  an 
hour-glass  appearance.  Interior  of  the  organ  contained  a  large  mass  of  hay 
and  fragments  of  bone.  New  opening  large  enough  to  pass  index  finger. 
Union  between  stomach  and  bowel  over  entire  surface  of  approximation. 
Water  passed  into  the  stomach  flowed  through  the  pyloric  orifice  and  the  new 
o | uning,  in  a  stream  of  equal  size. 

Experiment  57.  Large  bull-dog.  Approximation  of  anterior  surface  of 
stomach  with  bowel  by  perforated  gutta-peroha  plates,  and  four  catgut  sutures. 


440  EX-PERI  MENTAL   SURGERY- 

length  of  visceral  incisions,  two  inches.  The  day  after  operation  animal 
vomited  his  dinner,  subsequently  no  unfavorable  symptoms.  Animal  killed 
fourteen  days  after  operation.  Abdominal  wound  well  united.  Omentum 
adherent  to  wound,  duodenum,  liver  and  at  point  of  operation.  Firm  adhe- 
sions between  stomach  and  bowel.  Water  passed  into  the  stomach  only 
passed  through  the  pyloric  orifice.  On  opening  the  stomach,  it  was  found 
that  the  wound  in  the  stomach  and  intestine  had  completely  healed,  the  site  of 
incisions  being  marked  by  a  narrow  firm  cicatrix.  The  failure  of  obtaining 
an  anastomotic  opening  between  the  stomach  and  intestine  could  only  be 
attributed  to  one  of  two  causes,  viz.:  either  the  perforations  in  the  plates  were 
too  narrow,  or  the  needles  of  the  lateral  sutures  included  too  much  tissue. 
Either  cause  would  bring  about  approximation  of  the  margin  of  the  wounds 
and  permanent  closure  of  the  opening  by  granulation  and  cicatrization. 

Remarks. — All  of  the  animals  recovered,  except  in  case  of 
experiment  55,  without  any  untoward  symptoms,  although  they 
were  allowed  to  eat  immediately  after  the  operation,  and  the  diet 
was  not  selected  or  restricted  at  any  time.  In  the  fatal  case  death 
was  caused  from  complications  which  had  no  connection  with  the 
gastrointestinal  opening.  In  all  of  the  specimens  examined,  the 
mucous  membrane  of  the  stomach  and  intestine  which  had  been 
interposed  between  the  approximation  plates,  presented  a  healthy 
appearance,  showing  that  the  pressure  of  the  plates  had  exercised 
no  injurious  effect  on  this  structure.  More  recent  experience  with 
this  operation  on  animals  has  revealed  the  fact  that  in  the  stomach 
a  completely  decalcified  bone  plate  is  almost  entirely  digested  in 
thirty-six  to  forty-eight  hours.  It  would  therefore,  appear  advisable 
to  use  only  partially  decalcified  bone  which  remains  for  a  longer 
time,  so  that  in  case  of  delayed  union  the  approximation  would 
be  maintained  for  a  sufficient  length  of  time.  As  the  animals 
subjected  to  the  operation  recoyered  promptly,  and  under  the  most 
unfavorable  conditions,  we  have  every  reason  to  believe  that  this 
operation  will  be  attended  by  the  same  favorable  results  when  done 
for  pyloric  or  duodenal  stenosis  in  man,  where  a  careful  preparatory 
and  after  treatment  cannot  fail  to  facilitate  the  operation  and  to 
improve  the  conditions  for  the  formation  of  early  adhesions  and  a 
speedy  definitive  healing  of  the  wound.  I  have  no  hesitation  in 
recommending  it  as  a  substitute  for  the  more  time-consuming  and 
less  certain  operation  by  the  tedious  and  difficult  method  of  double 
suturing  which  is  now  generally  practiced. 


JEJUNO-ILEOSTOMY.  441 

2.     Jejuno-Ileostomy.  « 

In  this  operation  some  form  of  intestinal  obstruction  was  made; 
either  complete,  by  division  of  the  bowel  and  closure  of  both  ends, 
or  partial,  by  making  a  volvulus,  invagination  or  flexion  in  the  vicinity 
of  the  juncture  of  the  jejunum  with  the  ileum,  followed  by  estab- 
lishing a  communication  between  the  bowel  above  and  below  the 
obstruction.  Before  I  made  use  of  the  perforated  approximation 
discs,  this  was  accomplished  by  making  an  incision  an  inch  and  a  half 
or  two  inches  in  length  through  the  convex  surface  of  the  bowel 
above  and  below  the  obstruction,  and  uniting  the  wounds  by  a  double 
row  of  sutures.  An  operation  of  this  kind  usually  lasted  over  an 
hour,  while  the  rapid  operation  of  coaptation  by  perforated  discs 
seldom  took  more  than  fifteen  minutes. 

a.     Jejuno-Ileostomy  by  Suturing. 

Experiment  58.  Large  cat.  Invagination  of  ileum  into  ileum  in  a  down- 
ward direction,  and  fixation  of  intussusceptum  to  neck  of  intussuscipiens  by 
two  fine  catgut  sutures  to  prevent  spontaneous  reduction.  Intestinal  anasto- 
mosis by  establishing  an  opening  an  inch  in  length,  suturing  by  Czerny- 
Lembert  method.  The  animal  never  recovered  from  the  shock  of  the 
operation,  and  died  in  less  than  twenty-four  hours.  Length  of  intussusceptum 
two  inches,  which,  after  the  removal  of  the  sutures,  could  not  be  reached  by 
traction,  as  the  bowel  was  firmly  constricted  by  the  neck  of  the  intussuscipiens, 
and  recent  adhesions  had  formed.     No  peritonitis;  suturing  found  perfect. 

Experiment  59.  Dog,  weight  sixty-five  pounds.  Intestinal  obstruction  by 
making  acute  flexions  in  upper  portion  of  ileum;  fixation  of  loops  of  intestine 
by  fine  catgut  sutures.  Intestinal  anastomosis  between  jejunum  and  ileum 
by  incision  and  double  suturing.  The  animal  died  on  third  day  with  symp- 
toms of  perforative  peritonitis.  On  close  examination,  one  of  the  superficial 
approximation  sutures  had  been  passed  through  the  whole  thickness  of  the 
wall  of  the  bowel,  and  it  was  here  that  perforation  had  taken  place.  Recent 
diffuse  general  peritonitis.  • 

Experiment  60.  Dog,  weight  seventeen  pounds.  Descending  invagination 
of  ileum  into  ileum,  length  of  intussusceptum  three  inches,  fixation  by  two 
catgut  sutures.  Formation  of  intestinal  anastomosis  between  the  bowel 
above  and  below  the  invagination  by  incision  and  double  suturing.  Animal 
died  on  third  day  with  symptoms  of  perforative  peritonitis.  AJbdominal 
wound  not  united.  Adhesions  ;it  point  of  operation  quite  firm,  Diffuse 
general  peritonitis  from  a  perforation  which  had  been  made  bj  a  sharp 
fragment  of  I. one  above  the  new  opening.     [ntuBsnsoeptnm  not  gangrenous. 

Experiment  6 1 .  Dog,  weigh*  twenty  three  pounds,  [ntestinal  obstruction 
was  made  by  producing  a  volvulus  in  the  upper  part  of  the  ileum.  Restora- 
tion of  continuity  of  intestinal  canal  by  making  a  jejuno  ileostomy  bj  lateral 


442  EXPERIMENTAL  SURGERY. 

apposition  and  double  suturing.  Day  after  operation  intestinal  discharges 
were  bloody;  after  this  time  normal.  Animal  in  perfect  health  when  killed 
sixty-seven  days  after  operation.  The  volvulus  was  found  in  same  condition 
as  after  operation;  the  intestinal  loop  empty,  atrophied  and  adherent  to 
adjacent  loops  of  intestine.  Bowel  above  seat  of  obstruction  and  as  far  as 
the  new  opening  empty.  Intestinal  tract  above  and  below  the  obstruction 
presented  no  indication  of  the  presence  of  an  obstruction.  New  opening  oval 
in  shape  and  as  large  as  the  lumen  of  the  bowel  at  that  point. 

Experiment  62.  Large  Maltese  cat.  Intestinal  obstruction  by  making 
two  flexions  in  ileum,  about  eighteen  inches  apart,  after  this  portion  had  been 
cleared  of  its  contents.  Flexions  made  by  doubling  the  bowel  toward  its 
convex  side,  and  fixing  it  in  this  position  by  fine  catgut  sutures.  Jejuno- 
ileostomy  by  lateral  apposition  and  suturing.  Vomiting  day  after  operation; 
stools  scanty  the  first  few  days,  and  later  complete  obstruction.  Died  nineteen 
days  after  operation.  Wound  completely  united;  no  general  peritonitis; 
flexions  remained;  bowel  between  them  contained  a  slight  amount  of  faecal 
matter.  Bowel  some  distance  above  the  new  opening  very  much  dilated, 
pointing  to  obstruction  above  new  opening.  On  tracing  the  intestinal  canal 
from  above  downward,  this  obstruction  was  seen  to  consist  in  acute  flexion  of 
the  bowel  by  firm  and  extensive  adhesions.  New  opening  sufficiently  large  to 
admit  the  tip  of  the  index  finger,  around  the  margins  of  which  most  of  the 
deep  sutures  remained  attached. 

Experiment  63.  Large  cat.  Obstruction  made  by  two  flexions  in  the 
ileum,  the  apices  of  which  were  united  by  catgut  sutures.  Intestinal  anasto- 
mosis made  by  a  jejuno-ileostomy.  For  eleven  days  the  animal  remained  in 
good  condition,  when  symptoms  of  perforative  peritonitis  manifested  them- 
selves, and  death  ensued  two  days  later.  External  portion  of  wound  not 
united.  Numerous  omental  and  intestinal  adhesions.  Flexions  retained  and 
their  apices  adherent  to  each  other  by  firm  band  of  adhesion.  Excluded 
portions  above  and  below  the  obstruction  empty.  Two  small  perforations  at 
point  of  suturing  on  anterior  surface  of  bowel;  remaining  portion  of  wound 
firmly  united.  New  opening  sufficiently  large  to  admit  tip  of  index  finger. 
Death  from  perforative  peritonitis. 

Experiment  64.  Large,  Newfoundland  dog.  Descending  invagination  of 
ileum  into  ileum  to  the  extent  of  six  inches;  fixation  of  intussusceptum  by  two 
catgut  sutures.  Permeability  of  intestinal  canal  restored  by  making  a  jejuno- 
ileostomy;  wounds  united  by  a  double  row  of  sutures.  Intestinal  discharges 
normal  throughout.  No  rise  in  temperature.  General  condition  as  good  as 
before  operation,  when  killed  on  the  twentieth  day.  Abdominal  wound  com- 
pletely united;  no  peritonitis;  omentum  adherent  at  site  of  operation. 
Invagination  had  reduced  itself,  and  its  location  was  marked  by  an  acute 
flexion  caused  by  extensive  adhesions.  No  accumulation  of  intestinal  contents 
in  excluded  portions.  The  new  opening  at  least  two  inches  in  length;  a  few 
of  the  deep  sutures  remained  attached  to  its  margins.  This  opening  was 
partially  obstructed  by  a  mass  of  hair  and  fragments  of  bone.  On  passing  a 
stream  of  water  from  above  downward,  the  fluid  passed  through  an  opening  in 


JEJUNO-ILEOSTOM I  .  443 

the  centre  of  this  mass  into  the  lower  portion  of  the  ileum,  but  not  through  the 
portion  that  was  invaginated.  After  this  mass  was  removed,  the  fluid  was 
found  to  pass  through  the  portion  that  was  invaginated,  as  well  as  through  the 
new  opening. 

The  many  failures  which  attended  jejuno-ileostoruy  and  ileo- 
ileostomy  by  lateral  apposition  and  suturing,  led  to  the  use  of 
perforated  approximation  discs.  A  great  contrast  was  observed  in 
the  animals  operated  upon  by  these  two  methods.  The  operation  by 
suturing  required  usually  more  than  an  hour,  and  almost  all  of  the 
animals  showed  more  or  less  symptoms  of  shock  after  its  completion, 
and  not  a  few  succumbed  to  its  immediate  effects ;  while  the  opera- 
tion7 by  approximation  plates  could  always  be  finished  within  twenty 
minutes,  consequently  the  animals  never  suffered  seriously  from  the 
immediate  effects  of  the  operation.  The  first  experiments  were 
made  somewhat  carelessly  and  with  crude  material,  and  yet  it  was 
observed  that  the  healing  process  progressed  more  favorably  and 
was  accomplished  in  a  shorter  time  than  after  suturing.  The 
approximation  discs  brought  into  uninterrupted  contact  large  serous 
surfaces  without  impairing  the  vascular  supply;  at  the  same  time 
they  secured  for  the  parts  destined  to  become  united  an  essential 
condition  for  rapid  wound  healing — rest — by  serving  the  useful 
purpose  of  splints. 

Experiment  65.  Dog,  weight  fifteen  pounds.  Ileum  was  completely 
divided  at  its  junction  with  the  jejunum  and  both  ends  of  the  bowel  closed  by 
invagination,  and  three  stitches  of  the  continued  suture.  An  incision  was 
made  on  convex  side  of  bowel  about  two  inches  from  the  closed  ends,  and  a 
heavy  perforated  lead  plate  to  which  six  catgut  sutures  were  fastened  around 
the  oval  perforation,  was  introduced  into  the  lumen  of  the  bowel  of  each  closed 
end,  all  of  the  catgut  sutures  being  brought  out  through  the  incision.  The 
two  wounds  were  brought  opposite  each  other  and  the  six  sutures  tied.  The 
serous  surfaces  of  the  two  intestines  over  a  surface  corresponding  to  the  size 
of  the  lead  discs  were  thus  brought  into  accurate  apposition.  The  sutures 
were  cut  short  and  the  ends  buried  as  deeply  as  possible.  The  condition  of 
the  animal  remained  excellent  until  the  time  of  killing,  seventy-five  days  after 
operation.  Omentum  adherent  to  wound;  large  intestines  distended  with 
normal  faeces.  Bowel  above  and  below  point  of  operation  normal  in  size  and 
structure.  New  opening  between  ileum  and  jejunum  large  enough  to  admit 
the  little  finger  to  second  joint.  Bowels  firmly  united  by  a  broad  surface. 
Above  the  communicating  opening  a  double  flexion  of  the  bowel  was  found 
which  apparently  had  done  no  harm. 

Experiment  66.  Dog,  weight  eighteen  pounds.  Operation  done  in  the 
same  manner  as  in  the  last  experiment,  only  that  instead  of  Lead  the  discs 
were  made  of  sole  leather,  and  the  sutures  need  were  linen  in  place  of  oatgnt. 


444  EXPERIMENTAL   SURGERY. 

For  a  few  days  the  temperature  was  higher  than  normal  and  appetite  dimin- 
ished. After  fourth  day  the  animal  appeared  to  be  in  excellent  condition  and 
remained  so  for  three  weeks,  when  the  appetite  failed  and  occasional  attacks 
of  vomiting  set  in.  The  symptoms  remained  more  or  less  prominent  until 
the  time  of  killing,  thirty-nine  days  after  operation.  Omentum  adherent  to 
abdominal  wound  ;  extensive  intestinal  adhesions  at  site  of  operation  ;  union 
between  intestines  perfect.  On  incising  the  bowel  it  was  found  that  the  plates 
had  sloughed  through,  and  had  passed  along  the  distal  portion  of  the  bowel, 
leaving  an  opening  the  size  of  the  plates,  the  margins  of  which  had  almost 
completely  cicatrized.  The  two  leather  plates,  still  held  together  by  the  linen 
sutures,  were  found  three  feet  lower  down  in  the  ileum,  where  they  had  become 
embedded  in  a  mass  of  hair,  straw  and  fcecal  matter,  and  quite  firmly  impacted, 
causing  complete  obstruction  of  the  bowel.  The  intestine  above  the  seat  of 
obstruction  was  enormously  dilated,  while  below  the  seat  of  impaction  it  was 
empty  and  contracted.  Large  intestines  likewise  empty  and  contracted.  The 
cause  of  the  illness  was  evidently  due  to  intestinal  obstruction  produced  by 
the  impaction  of  the  large  enterolith,  in  the  center  of  which  the  leather  discs 
were  found. 

Experiment  67.  Dog,  weight  ten  pounds.  In  this  instance  the  bowel  was 
divided  near  the  junction  of  the  jejunum  with  the  ileum,  both  ends  closed, 
and  its  continuity  established  by  incising  the  convex  surface  of  both  ends, 
and  approximating  the  wounds  by  two  perforated  bone  plates  tied  together 
by  silk  ligatures.  The  animal  died  fourteen  days  after  operation.  During 
the  last  few  days  symptoms  of  intestinal  obstruction  were  present.  Abdominal 
wound  completely  united.  Numerous  intestinal  adhesions  at  site  of  operation. 
Bone  plates  still  in  situ  and  firmly  fixed.  On  proximal  side,  perforation  of 
bone  plates  completely  closed  by  hair  and  fragments  of  bone,  giving  rise  to 
complete  intestinal  obstruction.  The  bowel  above  this  point  was  greatly 
dilated,  while  on  distal  side  it  was  empty  and  contracted.  Firm  adhesions 
between  the  two  intestinal  surfaces  included  by  the  bone  plates.  Intestinal 
obstruction  by  a  mechanical  arrest  of  portion  of  the  intestinal  contents  above 
the  proximal  plate  had  caused  death  before  a  more  efficient  communication 
could  be  established  by  sloughing  through  of  the  bone  plates. 

Experiment  68.  Dog,  weight  thirty  pounds.  Ileo-ileostomy  by  dividing 
the  ileum  near  its  centre,  closing  both  sides,  and  after  incising  both  ends 
on  convex  surface,  bringing  wounds  in  apposition  by  perforated  plates  of 
cross-grained  walnut  wood,  which  were  tied  together  with  silk  sutures.  The 
dog  remained  in  perfect  health  and  was  killed  eighteen  days  after  operation. 
External  wound  completely  united.  Plates  had  become  detached,  leaving  a 
communicating  opening  two  inches  in  length.  Blind  ends  of  bowel  empty; 
no  trace  of  plates  could  be  found. 

Experiment  69.  Dog,  weight  twenty-four  pounds.  Double  ileo-ileostomy. 
Ileum  divided  transversely  five  inches  above  ileo-cgecal  region,  and  both  ends 
closed  by  invagination  and  three  stitches  of  the  continued  suture.  Lower 
and  upper  end  of  bowel  were  again  brought  into  communication  by  incision 
on  convex  side,  and  lateral  apposition  of   wounds  by  means  of  perforated 


JEJUN0-1LE0ST0MY.  44,") 

approximation  plates  of  decalcified  bone,  hardened  in  alcohol.  The  plaits 
were  fastened  together  by  four  silk  sutures,  all  of  the  threads  being  brought 
out  of  the  incision,  tied  and  cut  short.  Above  this  point  a  loop  of  the  ileum 
was  made  by  bringing  the  convex  surfaces  into  apposition  after  incision  at 
two  points,  and  introducing  perforated  gutta-percha  plates,  which  were 
retained  in  place  by  four  silk  sutures.  No  fever  or  symptoms  of  obstruction 
followed  the  operation.  Animal  killed  thirteen  days  later.  External  wound 
firmly  united.  No  evidences  of  peritonitis  or  intestinal  obstruction.  First 
operation  left  a  communicating  opening  large  enough  to  admit  the  little 
finger  in  one  of  its  margins.  The  silk  ligatures  which  had  become  detached 
from  the  plates  had  embedded  themselves.  The  decalcified  bone  plates  had 
disappeared  and  no  trace  of  them  could  be  found  in  any  portion  of  the  intes- 
tinal canal  lower  down.  The  second  operation  was  thirty  inches  higher  up. 
Gutta-percha  plates  remained  in  situ,  although  somewhat  loosened  by  the 
gradual  disappearance  of.  the  intervening  tissues  by  ■  pressure  atrophy. 
Adhesions  between  the  two  surfaces  of  the  bowel  firm,  and  extending  a  little 
beyond  the  line  of  approximation.  The  perforation  in  the  proximal  plate 
almost  completely  closed  by  an  accumulation  of  hair.  The  entire  ileum 
normal  in  size  and  appearance. 

Experiment  70.  Dog,  weight  fifty-four  pounds.  Transverse  section  of 
ileum  thirty  inches  above  ileo-caecal  region  and  closure  of  both  ends  in  the 
usual  manner.  The  two  closed  ends  were  overlapped  four  inches  and  brought 
into  communication  by  two  longitudinal  openings,  which  were  approximated 
by  being  buttoned  together  with  a  shuttle-shaped  button,  nearly  one  and  a 
half  inches  in  length,  the  sides  being  lead  plates  and  the  shaft  a  rubber  tube 
through  which  the  anastomosis  was  established  at  once.  As  the  margins  of 
the  intestinal  wounds  showed  a  tendency  to  evert,  a  fine  catgut  suture  was 
inserted  on  each  side  embracing  only  the  peritoneal  coat.  Only  for  two  or 
three  days  after  the  operation  did  the  dog  not  appear  to  be  well.  Killed 
twenty-three  days  after  operation.  Omentum  adherent  to  abdominal  wound 
which  was  firmly  united.  Omental  adhesions  to  intestine  at  site  of  operation. 
Intestinal  anastomosis  thirty  inches  above  the  ileo-caecal  valve.  Proximal 
blind  end  of  bowel  five  inches  in  length  adherent  to  distal  end,  considerably 
dilated  and  contained  fragments  of  bone  and  other  crude  substances.  Approx 
imation  button  in  situ  and  quite  firmly  fixed.  A  fragment  of  bone  partly  tilled 
the  lumen  of  the  rubber  tube.  Coaptated  peritoneal  surfaces  firmly  adherent. 
The  obstruction  of  the  communicating  tube  had  given  rise  to  dilatation  of  the 
bowel  above  the  point  to  twice  its  natural  size,  while  below  the  seal  of  partial 
obstruction  the  intestine  appeared  empty  and  contracted. 

Experiment  71.  Small  dog.  In  this  experiment  the  ileo-ileostonn  was 
made  by  lateral  apposition  by  perforated  approximation  (Mates  of  partially 
decalcified  bone  tied  together  by  tour  catgul  sutures.  The  lateral  BUtureswere 
passed  through  the  margins  of  the  wound  near  its  border,  a  modification  of 
the  usual  procedure,  which  not  only  fixed  the  plates  firmly  in  their  plaoes,  bnl 
also  prevented  ectropium  of  the  mucous  membrane,  and  ensured  tree  patency 
of  the  new  opening  by  retracting  the  margins  <>r  the  wound,  so  thai  the  Long] 


446  EXPERIMENTAL   SURGERY. 

tudinal  slit  was  at  once  transformed  into  an  oval  shape.  The  animal  showed 
no  unfavorable  symptoms  and  was  killed  twenty-nine  days  after  operation. 
Dog  well  nourished.  External  wound  united.  Omentum  adherent  to  wound 
and  intestines.  The  proximal  blind  end  of  bowel  contained  one  of  the  bone 
plates  which  showed  signs  of  softening  and  disintegration.  The  bone  plate 
in  the  distal  end  had  been  passed  with  faeces  previously.  The  new  opening 
perfect  and  sufficiently  large  to  equal  in  size  the  lumen  of  the  bowel. 

Experiment  72.  Dog,  weight  twelve  pounds.  Made  ileo-ileostomy  the 
same  as  in  the  last  experiment,  using  decalcified  perforated  bone  plates, 
which  were  tied  together  with  four  catgut  sutures,  the  lateral  ones  being 
passed  through  the  margins  of  the  wound.  An  omental  flap  was  used  to  cover 
the  sides  of  the  bowel  where  approximation  had  been  made.  This  flap  was 
retained  by  two  fine  catgut  sutures.  No  unfavorable  symptoms.  Animal 
killed  twenty-three-  days  after  operation.  Omentum  adherent  to  distal  blind 
end.  Omental  flap  in  position  and  firmly  adherent.  Site  of  operation  four- 
teen inches  above  ileo-csecal  region.  Both  bone  plates  had  disappeared  and 
no  trace  of  them  could  be  found.  Some  hair  had  collected  in  the  blind  proxi- 
mal end.     New  opening  large  enough  to  admit  the  index  finger. 

Remakks.  —  Jejuno- ileostomy  or  ileo-ileostomy  by  internal 
apposition  with  decalcified  perforated  bone  plates  in  cases  of  com- 
plete obstruction  of  the  bowel  artificially  produced,  is  an  operation 
almost  devoid  of  danger.  Partially  or  completely  decalcified  bone 
plates  hardened  in  alcohol  remain  firm  for  a  sufficient  length  of  time 
to  answer  the  purpose  of  retentive  measures,  until  firm  adhesions 
have  formed  between  the  serous  surfaces  held  by  them  in  approxi- 
mation. Until  it  was  ascertained  by  experiment  that  the  plates 
would  undergo  softening  and  disintegration  in  the  course  of  a  few 
days,  catgut  sutures  were  used  to  hold  them  in  place  with  the 
expectation  that  the  plates  would  become  detached  and  escape  with 
the  intestinal  contents  as  soon  as  the  sutures  would  give  way. 
Experience,  however,  has  shown  that  aseptic  silk  threads  are  prefer- 
able to  catgut,  as  they  can  be  tied  with  greater  accuracy  and  the 
knots  will  never  become  loosened,  while  the  approximation  discs 
disppear  completely  by  softening  and  disintegration  in  a  few  days. 
Approximation  plates  of  inabsorbable  material  as  lead,  wood,  leather, 
bone,  and  gutta-percha,  fastened  together  by  silk  or  linen  sutures, 
remain  in  situ  until  the  interposed  tissues  disappear  by  pressure 
atrophy,  and  the  opening  that  results  corresponds  in  size  to  the 
dimensions  of  the  plates.  In  the  first  experiments  the  plates  were 
tied  together  by  six  sutures,  but  it  was  found  that  four  sutures 
answered  the  same  purpose.     As  a  rule  the  plates  were  about  two 


ILEO-COLOSTOMY.  447 

and  a  half  inches  in  length,  and  their  width  corresponded  to  one- 
third  of  the  circumference  of  the  bowel.  The  greatest  advantage  to 
be  found  in  the  method  of  restoring  the  continuity  of  the  intestinal 
canal  by  lateral  apposition  by  approximation  discs,  consists  in  the 
fact  that  the  point  of  contact  is  always  made  on  the  convex  surface 
of  the  intestines,  so  that  the  means  employed  to  secure  coaptation 
do  not  interfere  with  the  blood  supply  from  the  mesenteric  vessels. 
As  this  method  requires  much  less  time  than  any  form  of  circular 
enterorrhaphy,  and  has  been  followed  almost  without  exception  by 
recovery,  it  recommends  itself  strongly  as  a  substitute  for  the  latter 
procedure  in  many  cases  where  loss  of  time  constitutes  an  important 
factor  in  the  issue  of  the  case,  or  where  from  other  causes  circular 
suturing  appears  impossible  or  impracticable. 

3.     Ileo-Colostomy. 

As  the  ileo-caecal  region  is  frequently  the  seat  of  intestinal 
obstruction,  it  becomes  desirable  to  devise  some  definite  plan  of 
operative  treatment  in  cases  where  the  cause  of  obstruction  is  not 
amenable  to  removal,  with  a  view  of  establishing  the  continuity  of 
the  intestinal  canal,  thus  avoiding  the  necessity  of  resorting  to  the 
formation  of  an  artificial  anus.  To  accomplish  this  object  two 
distinct  methods  were  followed  :  1.  Division  of  the  ileum  with 
closure  of  distal  and  implantation  of  proximal  end  into  colon.  2. 
Division  of  ileum,  closure  of  both  ends  and  lateral  apposition  of 
proximal  end  with  colon,  and  the  formation  of  an  intestinal  anasto- 
mosis by  suturing  or  approximation  discs. 

a.    Ileo-Colostomy  by  Implantation. 

Experiment  73.  Dog,  weight  thirty-eight  pounds.  Intestinal  anastomosis 
by  implantation  of  ileum  into  colon.  The  ileum  was  divided  transversely 
just  above  the  ileo-csecal  region,  and  the  distal  end  closed  by  invagination  and 
three  stitches  of  the  continued  suture,  and  dropped  back  into  the  abdominal 
cavity.  A  longitudinal  incision,  in  size  corresponding  to  the  lumen  of  the 
ileum,  was  made  in  the  ascending  colon  at  a  point  directly  opposite  the 
mesentric  attachment,  and  the  proximal  end  of  the  ileum  was  then  fixed  in 
this  opening  by  Czerny-Lembert sutures.  Only  Blight  febrile  reaction  followed 
the  operation.  The  appetite  remained  good  and  the  discharges  from  the 
bowels  were  normal.  The  animal  was  in  excellent  condition  when  killed. 
thirty-three  days  after  operation.  Pew  ciroumacribed  omental  adhesions  to 
abdominal  woui.d,  which  was  completely  closed.  Peripheral  portion  of  ileum 
presented  a  conical  appearance,  and  was  found  adherent  to,  and  of  tho  same 
length  as  the  appendix  vermiformis.     Implantation  had  been  done  about  the 


448  EXPERIMENTAL  SURGERY. 

middle  of  the  colon.  Union  at  point  of  suturing  perfect,  apparently  no 
interruption  of  continuity  of  peritoneal  surface.  The  new  opening  into 
colon  a  little  smaller  than  the  lumen  of  the  ileum.  Around  the  margins  of 
this  opening,  which  somewhat  resembled  the  ileo-ctecal  valve,  six  of  the  deep 
silk  sutures  remained  attached.  Above  the  new  opening  the  colon  and  caecum 
were  found  empty  and  somewhat  atrophic.  Lower  portion  of  the  ileum  and 
colon  below  the  new  opening  appeared  normal  in  size  and  structure. 

Remarks. — In  the  remaining  experiments  the  implantation  was 
made  by  lining  the  proximal  end  of  the  ileum  with  a  narrow  flexible 
rubber  ring,  which  was  retained  in  place  by  a  continued  catgut 
suture,  embracing  the  free  margin  of  the  bowel  and  the  lower  margin 
of  the  rubber  ring.  The  implantation  was  made  by  two  catgut 
sutures,  threaded  each  by  two  needles  and  passed  at  opposite  points 
from  within  outwards  through  the  upper  margin  of  the  ring  and  the 
entire  thickness  of  the  bowel,  while  the  needles  were  only  passed 
through  the  serous  and  muscular  coats  of  the  colon.  After  both 
sutures  were  in  place  gentle  traction  upon  all  of  the  ends  brought 
the  end  of  the  ileum  into  the  incision  in  the  colon,  and  the  walls  of 
the  colon  were  drawn  over  the  end  of  the  ileum  to  the  points  where  the 
needles  emerged  from  the  ileum,  making  really  a  limited  invagination. 
When  in  proper  position,  the  serous  surfaces  of  the  colon  and  ileum 
over  a  surface  corresponding  to  the  width  of  the  rubber  ring  were  in 
accurate  coaptation,  after  the  two  sutures  were  tied.  Only  in  excep- 
tional cases  was  it  found  necessary  to  apply  one  or  two  additional 
superficial  coaptation  sutures.  As  in  circular  enterorrhaphy,  so  in 
these  cases,  the  elastic  pressure  on  the  part  of  the  rubber  ring  ren- 
dered material  assistance  in  maintaining  accurate  coaptation,  while 
at  the  same  time  it  secured  rest  for  the  sutured  parts,  and  kept  the 
new  opening  freely  patent  for  the  escape  of  intestinal  contents  into 
the  colon.  This  operation  did  not  require  one-fourth  of  the  time 
consumed  in  making  an  implantation  by  Czerny-Lembert  sutures. 

Experiment  74.  Dog,  weight  fifty  pounds.  Division  of  ileum  eight 
inches  above  ileo-csecal  region,  distal  end  closed  by  invagination,  and  three 
stitches  of  the  continued  suture.  Proximal  end  lined  with  rubber  ring  and 
implanted  into  incision  of  ascending  colon  by  two  catgut  invagination  sutures. 
The  dog  did  not  appear  to  do  well  after  the  operation,  and  died  on  the  fifth 
day.  Abdominal  wound  not  united.  Partial  separation  of  implanted  bowel 
and  diffuse  septic  peritonitis  from  perforation. 

Experiment  75.  Dog,  weight  thirty-five  pounds.  Ileum  divided  twelve 
inches  above  ileo-caecal  region,  distal  end  closed  and  proximal  end  lined  with 
flexible  rubber  ring  and  implanted  into  an  incision  in  the  transverse  colon, 


ILEOCOLOSTOMY.  449 

and  retained  by  two  invagination  sutures  of  catgut.  An  omental  flap  an  inch 
and  a  half  in  width  was  placed  over  the  junction  of  the  two  intestines  and  fixed 
in  its  place  by  two  catgut  sutures.  No  unfavorable  symptoms  after  operation. 
Animal  when  killed  eighteen  days  later,  in  excellent  condition.  Omentum 
adherent  to  abdominal  wound  which  was  firmly  united.  Omental  flap  adherent 
all  round.  Colon  above  new  opening  ten  inches  in  length,  completely  empty, 
contracted  and  atrophic.  New  opening  oval  in  outline  and  as  large  as  the 
lumen  of  the  ileum. 

Experiment  76.  Dog,  weight  sixteen  pounds.  Division  of  ileum,  closure 
of  distal  end  and  implantation  of  proximal  into  an  incision  of  the  colon  by 
rubber  ring  and  two  invagination  sutures  of  catgut.  As  the  inverted  portions 
of  the  colon  showed  a  tendency  to  evert,  two  additional  retaining  sutures  of 
fine  catgut  were  used,  which  secured  perfect  coaptation  throughout.  An 
omental  flap  was  laid  over  the  junction  of  the  intestines  and  fixed  in  its 
place  by  one  catgut  suture.  The  dog  remained  in  good  condition,  appetite 
unimpaired,  and  discharges  from  bowels  normal.  Killed  thirteen  days  after 
operation.  Abdominal  wound  firmly  united.  Omentum  adherent  to  wound. 
A  number  of  adhesions  between  coils  of  intestine.  Ileum  somewhat  dilated 
above  the  new  opening.  Omental  flap  in  place  and  adherent.  Union  between 
ileum  and  colon  perfect.  A  long,  sharp  fragment  of  bone  was  found  lodged 
just  above  the  new  opening,  the  lower  end  partially  occluding  its  lumen.  The 
dilatation  of  the  lower  portion  of  the  ileum  was  evidently  due  to  partial 
obstruction  from  the  presence  of  the  foreign  body  in  the  new  opening. 

Experiment  77.  Dog,  medium  size.  Section  of  ileum  two  feet  above  the 
ileo-caecal  region,  closure  of  distal  end  in  the  usual  manner,  implantation  of 
proximal  end  into  colon  by  rubber  ring  and  two  invagination  sutures  of  cat- 
gut. No  omental  flap.  Animal  remained  well  and  was  killed  forty-three 
days  after  operation.  Omentum  adherent  to  abdominal  wound.  Distal  end 
of  ileum  conical  in  shape,  the  extremity  presenting  a  cup-shaped  depression, 
which  was  filled  with  cicatricial  material.  Omentum  adherent  at  ileo-crocal 
region  and  at  site  of  operation.  Union  between  the  bowels  perfect  and  their 
serous  surfaces  appeared  to  be  continuous  over  the  line  of  junction.  The  new 
opening  from  the  colon  admitted  the  little  finger,  and  was  surrounded  by  a 
prominent  ridge  of  mucous  membrane,  which  resembled  the  ileo-coacal  valve. 

Experiment  78.  Dog,  weight  fourteen  pounds.  Division  of  ileum  a  few 
inches  above  ileo-caecal  valve,  distal  end  closed  by  invagination,  and  three 
stitches  of  continued  suture.  Implantation  of  proximal  end  into  colon  by 
rubber  ring  and  two  catgut  invagination  sutures.  Over  the  junction  of  the 
two  intestines  an  omental  flap  was  placed  which  was  retained  by  a  catgut 
suture.  The  animal  showed  no  unfavorable  symptoms  and  was  killed  twenty- 
three  days  after  operation.  Omental  flap  retained  and  firmly  adherent 
throughout.  Point  of  implantation  three  inches  above  cacuin;  union  between 
the  two  intestines  firm  throughout.  New  opening  corresponded  in  size  to  the 
lumen  of  the  ileum,  and  was  surrounded  by  a  prominent  ridge  of  mucous 
membrane  which  appeared  to  be  derived  from  the  invaginated  portion  of  the 
ileum. 


450  EXPERIMENTAL  SURGERY. 

Experiment  79.  Ileum  divided  a  few  inches  above  ileo-caecal  region,  and 
after  closure  of  the  distal,  the  proximal  end  was  implanted  into  the  colon  in 
the  usual  manner  by  a  rubber  ring  and  two  invagination  sutures  of  catgut. 
Animal  died  on  third  day  after  operation.  Wound  partially  united;  a  con- 
siderable quantity  of  sero-sanguinolent  fluid  in  the  abdominal  cavity.  Ileum 
almost  completely  separated  from  colon,  and  the  portion  which  had  been 
invaginated  showed  signs  of  gangrene.  Eubber  ring  had  disappeared;  death 
from  perforative  peritonitis.  In  this  case  we  have  reason  to  believe  that  the 
rubber  ring  which  was  used  was  too  large,  and  that  the  gangrene  and  separa- 
tion was  due  to  injurious  pressure. 

b.    Ileo-Colostomy  by  Lateral  Apposition. 

Anastomosis  by  this  method  was  made  after  producing  an 
intestinal  obstruction  of  some  kind  at  or  near  the  ileo-caecal  region, 
and  then  by  bringing  the  ileum  above  the  seat  of  obstruction  in 
communication  with  the  colon  below  the  point  of  obstruction,  by 
making  an  incision  an  inch  and  a  half  to  two  inches  in  length  in  both 
intestines  at  a  point  opposite  the  mesenteric  attachments,  and  unit- 
ing the  wounds  either  by  a  double  row  of  sutures  or  perforated 
decalcified  bone  discs.  The  first  experiments  were  all  made  by 
suturing  but,  as  in  circular  enterorrhaphy.  it  was  found  by  experi- 
ence that  perforation  not  infrequently  occurred  along  the  track  of 
one  of  the  sutures,  in  some  instances  several  days  after  the  operation, 
at  a  time  when  union  had  taken  place  by  firm  adhesions.  These 
unfavorable  results  led  to  the  use  of  the  approximation  discs. 

Experiment  80.  Dog,  weight  twenty-five  pounds.  The  ileum  was  with- 
drawn from  the  abdomen  through  an  incision  in  the  linea  alba,  and  having 
emptied  a  loop  of  its  contents,  acute  flexion  was  made  just  above  the  ileo-caecal 
region  by  approximating  the  serous  surfaces  of  the  convex  side  for  a  inch  and 
a  half  by  five  catgut  sutures.  Two  longitudinal  incisions  of  equal  size  were 
made,  one  in  the  ileum  six  inches  above  the  flexion,  and  the  other  in  the 
ascending  colon  three  inches  above  the  caecum.  The  visceral  wounds  were 
carefully  united  by  Czerny-Lembert  sutures,  using  silk  for  the  deep  interrupted 
sutures,  and  fine  catgut  for  the  superficial  continued  sutures.  No  untoward 
symptoms  were  observed  after  the  operation;  appetite  remained  unimpaired, 
and  faecal  discharges  were  normal.  The  dog  was  killed  thirty-seven  days  after 
operation.  Animal  well  nourished.  No  evidences  of  peritonitis.  Bowel  above 
point  of  obstruction  nearly  empty,  and  somewhat  contracted  as  far  as  the  new 
opening.  Flexion  permeable  to  a  stream  of  water.  Slight  omental  adhesions 
to  bowel  at  site  of  operation;  union  firm  throughout.  Lumina  of  non-excluded 
portion  of  bowel  normal  in  size  above  and  below  the  flexion.  Serous  surfaces 
at  point  of  junction  appeared  perfect  and  continuous.  On  slitting  open  the 
colon  opposite  the  new  opening,  its  outlines  were  seen  to  be  marked  by  a 
prominent  ridge  of  mucous  membrane  to  which  a  number  of  the  deep  sutures 


ILEO-COLOSTOMY.  451 

remained  attached.  The  opening  was  large  enough  to  admit  the  tip  of  the 
middle  finger.  The  excluded  portion  of  the  colon  and  the  cecum  were  some- 
what contracted  and  atrophic,  and  contained  only  a  very  small  quantity  of 
faecal  matter. 

Exj)eriment  SI.  Medium-sized  cat.  About  two  inches  of  the  ileum  were 
invaginated  into  the  colon  through  the  ileo-cascal  valve,  and  the  intussusceptum 
stitched  to  the  neck  of  the  intussuscipiens  by  two  fine  catgut  sutures. 
Continuity  of  the  intestinal  canal  restored  by  incising  the  ileum  above  the 
obstruction,  and  the  ascending  colon  below  the  free  extremity  of  the  intussus- 
ceptum, and  uniting  the  wounds  by  a  double  row  of  sutures.  The  invagination 
caused  no  serious  disturbance,  and  the  animal  remained  in  good  health  and 
was  in  excellent  condition  at  the  time  of  killing,  one-hundred  and  sixty-two 
days  after  operation.  A  number  of  adhesions  between  the  folds  of  the  intes- 
tines near  the  site  of  operation.  At  point  of  juncture  of  the  two  intestines  the 
peritoneal  surface  presented  a  glistening  and  continuous  surface.  New  open- 
ing an  inch  and  a  half  in  length,  oval  in  outline  and  located  five  inches  above 
the  ileo-cascal  region.  Two  inches  below  the  opening  the  invagination  remained 
in  the  shape  of  a  circular  thickening  of  the  bowel  with  a  narrowing  of  its 
lumen  to  more  than  one-half  of  its  normal  size.  A  close  inspection  of  the 
specimen  showed  that  no  gangrene  had  occurred,  but  that  the  intussusceptum 
had  undergone  atrophy.  A  stream  of  water  passing  along  the  ileum  in  a 
downward  direction  escaped  through  the  invaginated  portion  and  through  the 
new  opening,  the  stream  from  the  latter  being  at  least  three  times  larger 
than  the  one  through  the  intussusceptum.  Excluded  portion  of  ileum  and 
colon  empty  and  very  much  atrophied  and  contracted.  Below  the  new  open- 
ing the  colon  and  rectum  contained  normal  faaces  in  considerable  quantity. 

Experiment  82.  Young  cat.  Ileo-csecal  invagination;  length  of  intussus- 
ceptum four  inches.  In  order  to  prevent  spontaneous  disinvagination  the 
bowel  was  fixed  in  its  position  by  two  fine  catgut  sutures.  Ileo-colostomy 
below  the  lower  end  of  tho  intussusceptum  by  lateral  apposition  and  suturing. 
Animal  died  on  the  fourth  day  after  operation.  Abdominal  wound  united. 
Diffuse  peritonitis  from  perforation  at  site  of  suturing.  Length  of  intussus- 
ceptum reduced  from  four  inches  to  two  inches  and  a  half.  It  was  found 
impossible  to  effect  reduction  by  traction  on  account  of  firm  adhesions  at  neck 
of  intussuscipiens.     No  gangrene. 

Experiment  83.  Adult,  large  dog.  Intestinal  obstruction  was  produced 
by  making  two  sharp  flexions  near  the  ileo-cascal  region  by  folding  the  bowel 
on  its  side  and  fixing  it  in  this  position  by  fine  catgut  sutures;  the  apices  of 
the  flexions  were  sutured  together  so  as  to  render  the  obstruction  more  com- 
plete. Intestinal  anastomosis  was  established  by  lateral  apposition  and 
suturing.  Physical  condition  of  dog  remained  good  throughout ;  appetite  and 
evacuations  normal.  Killed  thirty-one  days  after  operation.  N<>  peritonitis; 
a  number  of  omental  adhesions  at  point  of  operation.  Flexions  quite  sharp, 
rendering  the  bowel  nearly,  if  not  completely,  impermeable  at  this  point. 
Perfect  union  between  bowels,  with  some  thickening  of  their  walls  by  inflam- 
matory exudation.     New  opening  oval  in  shape,  an  inch  and  a  half  in  length, 


452  EXPERIMENTAL  SURGERY. 

a  few  of  the  deep  sutures  still  remaining  attached  to  its  margins.     Excluded 
portion  of  bowel  empty  and  somewhat  atrophic. 

Experiment  84.  Dog,  weight  thirteen  pounds.  Obstruction  of  the  bowels 
made  by  an  acute  flexion  four  inches  above  the  ileo-caecal  region,  retained  by 
four  catgut  sutures.  Intestinal  anastomosis  by  an  opening  an  inch  and  a 
half  in  length,  which  brought  into  communication  the  ileum  above  the  obstruc- 
tion and  the  descending  colon.  The  animal  showed  no  untoward  symptoms,  and 
was  killed  forty-one  days  after  operation.  A  number  of  intestinal  folds 
agglutinated  by  adhesions;  no  evidences  of  diffuse  peritonitis.  Where  the 
flexion  had  been  made  the  loop  of  intestine  was  connected  by  a  broad  band  of 
adhesion  which  gave  to  the  bowel  a  horse-shoe  shaped  appearance.  Intestine 
below  the  seat  of  flexion  contained  a  small  amount  of  hardened  faeces.  Colon 
and  caecum  above  the  new  opening  nearly  empty  and  greatly  contracted. 
Line  of  suturing  somewhat  thickened.  New  opening  oval  in  outline  and 
about  an  inch  in  length,  surrounded  by  a  corrugated  elevation  of  mucous 
membrane.  A  stream  of  water  passed  through  the  bowel  from  above  down- 
ward readily  escaped  through  the  new  opening,  while  only  a  small  stream  could 
be  forced  through  the  flexion. 

Experiment  85.  Dog,  weight  twenty-seven  pounds.  A  volvulus  was  made 
six  inches  above  the  ileo-caecal  region  by  rotating  an  empty  loop  of  the 
intestine  once  around  its  axis,  and  fixing  it  in  this  position  by  three  catgut 
sutures.  Intestinal  anastomosis  between  the  ileum  above  the  volvulus  and  the 
descending  colon  by  lateral  apposition  and  suturing.  For  four  days  after  the 
operation  the  evacuations  from  the  bowels  contained  blood;  after  this  time 
the  stools  were  normal.  Dog  in  excellent  condition  when  killed  thirty-one 
days  after  operation.  No  signs  of  diffuse  peritonitis.  The  portion  of  bowel 
which  constituted  the  volvulus  adherent,  contracted  and  empty.  Water  could 
be  readily  forced  through  this  part  of  the  bowel.  Caecum  and  colon  above 
new  opening  empty  and  contracted.  Size  of  new  opening  larger  than  the 
lumen  of  the  ileum,  its  margins  surrounded  by  a  prominent  ridge  of  mucous 
membrane  to  which  a  few  of  the  deep  sutures  still  remained  attached.  In  this 
experiment  nearly  the  entire  colon  was  excluded,  consequently  the  faecal  dis- 
charges were  quite  frequent  and  fluid  or  semi-fluid  in  consistence. 

Experiment  86.  Dog,  weight  seventeen  pounds.  Two  inches  of  the  ileum 
were  invaginated  into  the  caecum.  Ileo-colostomy  by  uniting  the  ileum  with 
the  transverse  colon  by  suturing.  The  animal  appeared  quite  ill  after  the 
operation  and  died  on  the  fifth  day  after  having  manifested  well-marked 
symptoms  of  perforative  peritonitis.  Abdominal  wound  not  united.  Only 
partial  union  between  the  intestines  at  point  of  junction.  Diffuse  septic 
peritonitis  from  perforation. 

Remarks. — In  at  least  two  experiments  which  are  not  here 
reported,  the  animals  died  of  shock  a  few  hours  after  operation.  In 
a  number  of  other  experiments  the  operation  was  followed  by  more 
or  less  shock,  but  the  animals,  without  receiving  any  special  treat- 
ment, rallied  after  six  to  twelve  hours.      The  symptoms  referable  to 


ILEO-COLOSTOMY.  453 

the  immediate  effects  of  the  operation  were  due  to  the  length  of 
time  required  in  applying  a  double  row  of  sutures  in  uniting  the 
visceral  wounds,  a  step  in  the  operation  which  always  required  from 
thirty  minutes  to  an  hour.  These  experiments  only  corroborate  the 
statement  previously  made  that  the  excluded  portion  of  the  intestinal 
canal,  including  the  obstruction,  does  not  become  the  seat  of .  f recal 
accumulation,  but  undergoes  atrophy  after  free  intestinal  anastomosis 
Luis  been  established  between  the  intestine  above  and  below  the  seat 
of  obstruction.  Experiments  Nos.  70  and  71  furnish  most  striking 
proof  that  the  danger  of  gangrene  in  cases  of  invagination  is  greatly 
diminished  by  establishing  an  early  intestinal  anastomosis,  as  when 
this  is  done  the  violent  peristalsis  is  promptly  arrested  by  furnishing 
a  new  outlet  to  the  intestinal  contents  ;  at  the  same  time,  the  serious 
consequences  resulting  from  pressure  and  distention  above  the 
obstruction  are  likewise  promptly  averted.  In  cases  of  intestinal 
anastomosis  where  nearly  the  entire  colon  has  been  excluded,  the 
fluid  contents  of  the  small  intestines  reach  the  rectum  at  once,  and 
cause  frequent  fluid  faecal  discharges,  an  occurrence  which  does  not 
appear  to  impair  the  general  health  of  the  animal.  The  new  open- 
ing shoiald  be  made  of  adequate  size,  so  that  its  lumen  will  at  least 
correspond  to  the  lumen  of  the  bowel  above  the  obstruction. 

c.     Ileo-Oolostoiny  by  Perforated  Approximation  Discs. 

Experiment  87.  Dog,  weight  twenty  pounds.  The  ileum  was  completely 
divided  three  inches  above  the  ileo-csecal  region,  both  ends  closed  by  invagi- 
nation and  three  stitches  of  the  continued  suture.  A  communication  was 
established  between  the  proximal  extremity  and  the  colon,  by  making  an 
incision  into  the  ileum  on  convex  side  near  the  closed  end  and  introducing 
through  this  opening  a  perforated  decalcified  bone  plate.  A  similar  opening 
was  made  into  the  ascending  colon  opposite  its  mesenteric  attachment, 
through  which  a  perforated  plate  of  wood  was  introduced.  To  each  plate 
were  tied  four  catgut  sutures.  The  lateral  sutures  were  passed  through  the 
margins  of  the  wound.  After  the  plates  and  sutures  were  in  place  the  wounds 
were  brought  in  contact  and  the  four  sutures  tied,  which  coaptated  the  Berous 
surfaces  of  both  bowels  over  an  area  corresponding  to  the  size  of  the  plates. 
The  animal  remained  apparently  well  for  two  days,  when  symptomB  of 
peritonitis  set  in  and  death  occurred  live  days  after  operation.  Diffuse 
peritonitis.  Union  at  point  of  operation  incomplete,  which  resulted  in  a 
perforation.  Discs  hud  disappeared.  &.B  the  catgut  sutures  were  quite  fine  it 
is  more  than  probable  that  partial  separation  of  the  plates  occurred  before 

adhesions  had  taken  place  between  the  serous  surfaces  of  the  coaptated  bow- 
els, which  resulted  in  perforation  and  deatli  from  diffuse  septic  peritonitis. 


454  EXPERIMENTAL  SURGERY. 

Experiment  88.  Dog,  weight  fifteen  pounds.  Invagination  of  colon  into 
colon  to  the  extent  of  two  inches.  Intestinal  anastomosis  by  making  an  ileo- 
colostomy  by  lateral  apposition  of  the  ileum  to  colon  below  invagination, 
using  perforated  hard  rubber  plates  which  were  tied  together  by  four  catgut 
sutures,  the  lateral  sutures  being  passed  through  the  margins  of  the  wound. 
After  tying  the  sutures  it  was  found  that  at  one  point  the  margins  of  the 
wound  showed  a  tendency  to  evert,  consequently  a  fine  catgut  suture  was 
passed  through  the  peritoneum  only  and  tied.  The  animal  did  not  appear 
bright  the  day  after  the  operation,  but  subsequently  showed  no  signs  of 
suffering;  killed  twenty -four  days  after  operation.  Abdominal  wound  firmly 
united.  Omentum  adherent  to  wound  and  at  point  of  operation.  The  in- 
vagination was  partially  reduced.  The  bowel  at  this  point  was  curved  in  the 
shape  of  a  horse-shoe,  but  permeable  to  a  stream  of  water.  Excluded  portion 
of  colon  tortuous  and  atrophic.  Caecum  contained  a  small  quantity  of  fluid 
fasces.  Plates  could  not  be  found.  New  opening  sufficiently  large  for  free 
passage  of  intestinal  contents. 

Experiment  89.  Dog,  weight  fifteen  pounds.  Ileum  divided  transversely 
fifteen  inches  above  the  ileo-csecal  region;  both  ends  closed  in  the  usual 
manner.  Ileum  and  colon  approximated  by  decalcified  perforated  bone 
plates  which  were  tied  together  by  four  catgut  sutures,  the  lateral  ones 
transfixing  the  margins  of  the  wound.  On  the  second  day  the  evacuation  from 
the  bowels  contained  traces  of  blood.  Animal  killed  eighteen  days  after  opera- 
tion. Abdominal  wound  completely  healed.  Omentum  adherent  to  wound. 
Numerous  adhesions  between  the  intestinal  folds.  Proximal  blind  end  of 
ileum  had  been  changed  into  a  pouch-like  form  and  contained  a  mass  of  hair 
and  fragments  of  bone.  One  very  sharp  spiculum  of  bone  had  nearly  perfo- 
rated the  intestine.  New  opening  corresponded  in  size  to  the  lumen  of  the 
ileum. 

Remarks. — The  operations  of  lateral  apposition  of  ileum  to  colon 
by  perforated  approximation  discs,  have  shown  that  it  is  unsafe  to 
rely  upon  catgut  as  a  suturing  material,  as  when  fine  catgut  is  used 
coaptation  is  not  maintained  for  a  sufficient  length  of  time  for 
adhesions  to  take  place,  and  coarse  catgut  when  tied  interferes 
with  accurate  approximation,  as  the  knots  after  tying  mechanically 
separate  the  serous  surfaces.  It  is  advisable  to  use  removable  plates 
and  to  tie  with  silk.  The  results  of  ileo-colostomy  made  by  approxi- 
mation discs  have  not  been  as  favorable  as  after  jejuno-ileostomy  or 
ileo- ileostomy,  and  in  repeating  the  operation  on  man  it  would  be 
indicated,  after  bringing  the  intestines  in  apposition  by  tying  the 
four  sutures,  to  apply  a  number  of  superficial  sutures  for  the  pur- 
pose of  still  further  guarding  against  the  escape  of  gas  or  fluid 
contents  into  the  peritoneal  cavity.  The  plates  when  properly  fixed 
in  their  places  and  tied  together  with  sufficient  firmness,  not  only 


ILEO-RECTOSTOMY.  455 

coaptate  an  extensive  area  of  serous  surfaces,  but  they  at  the  Bame 
time  secure  perfect  rest  for  the  parts  which  it  is  intended  to  unite, 
until  firm  adhesions  have  formed. 

4.    Ileo-Rectostomy. 

In  cases  of  intestinal  obstruction  due  to  inoperable  conditions 
low  down  in  the  colon,  it  becomes  necessary  to  establish  an  intestinal 
anastomosis  between  the  ileum*  and  the  rectuni,  in  order  to  avert  the 
necessity  of  making  an  artificial  anus;  in  other  words,  to  make  an 
ileo-rectostomv.  The  operation  can  be  made  in  the  same  way  as 
establishing  a  communication  between  the  ileum  and  the  colon  by 
lateral  implantation,  by  lateral  apposition  and  double  suturing,  or 
by  lateral  apposition  by  perforated  decalcified  bone  plates.  The 
operation  is,  however,  more  difficult  because  the  rectum  is  not  as 
accessible  as  the  colon,  and  from  the  greater  vascularity  of  the  gut, 
the  incision  is  more  liable  to  give  rise  to  troublesome  hemorrhage. 
While  the  slight  hemorrhage  from  an  incision  into  the  small  intes- 
tines and  the  colon  is  usually  promptly  arrested  by  suturing,  or 
compression  by  the  approximation  discs,  the  bleeding  from  a  wound 
of  the  upper  portion  of  the  rectum  not  infrequently  requires  the 
application  of  one  or  more  catgut  ligatures  before  it  is  safe  to  unite 
the  wounds.  During  the  operation  traction  must  be  made  upon  the 
rectum  in  an  upward  direction  so  as  to  lift  the  upper  portion  of 
the  bowel  out  of  the  pelvis.  In  both  of  the  experiments  described 
below,  the  wounds  were  united  by  Czerny  Lembert  sutures. 

Experiment  90.  Dog,  weight  ninety  pounds.  Invagination  of  colon  into 
colon  for  two  inches  and  suturing  of  intussusceptum  to  neck  of  intussuscipiens 
by  four  fine  silk  sutures  to  prevent  spontaneous  disinvagination.  Ileum 
incised  in  a  parallel  direction  for  an  inch  and  a  half  on  convex  side,  and  this 
wound  united  with  a  similar  incision  in  the  rectum  on  its  anterior  surface  by 
a  double  row  of  sutures.  For  the  purpose  of  immobilizing  the  sutured  intes- 
tines  an  additional  fine  catgut  suture  was  applied  above  and  below  the  place 
of  suturing,  embracing  only  the  peritoneal  and  muscular  coats  of  the  intes- 
tines.  pn  the  third,  fourth,  and  fifth  days  the  faecal  discharges  contained 
blood  and  mucus.  On  the  sixth  day  the  abdominal  wound  partially  opened, 
and  a  considerable  quantity  of  sero-puruleni  fluid  --<';i  ped.  Death  seven  days 
after  operation.  Abdominal  wound  not  united.  Diffuse  purulent  peritonitis. 
Numerous  intestinal  adhesions.  Invagination  retained:  adhesions  between 
the  intussusceptum  and  intussuscipiens;  no  gangrene;  perforation  at   point  of 

operation. 

E.rj/rriiurnl    .''/.      Cat,   weight    seven    pounds.      Ileo  rectostom J     by    lateral 

implantation.    The  ileum  was  out  across  transversely  an   Inch  above  the  ileo- 


456  EXPERIMENTAL  SURGERY. 

ctecal  valve,  and  the  distal  end  closed  by  invagination  and  three  stitches  of 
the  continued  suture.  The  proximal  end  was  transplanted  into  a  longitudinal 
incision  on  the  anterior  surf  ace  of  the  upper  portion  of  the  rectum  by  Czerny- 
Lembert  sutures.  With  the  exception  of  an  occasional  slight  rise  in  tempera- 
ture no  serious  disturbances  were  observed  during  the  progress  of  the  case. 
The  evacuation  of  the  small  intestines  directly  into  the  rectum  appeared  to 
increase  the  peristaltic  action  of  the  rectum,  as  the  faecal  discharges  were  fluid 
and  frequent.  Animal  killed  twenty  days  after  operation.  Abdominal  wound 
completely  united.  No  peritonitis.  A  few  folds  of  the  small  intestines  and 
the  omentum  adherent  to  the  wound.  Insertion  of  ileum  into  rectum  in  an 
oblique  direction;  union  at  point  of  junction  complete  throughout;  intestinal 
coats  at  this  point  somewhat  thickened.  Peritoneal  surface  smooth  and  con- 
tinuous from  one  bowel  to  the  other.  New  ileo-rectal  opening  corresponded  in 
size  to  the  lumen  of  the  ileum;  margins  of  this  opening  consisted  of  a  ridge  of 
mucous  membrane  to  which  a  row  of  the  deep  sutures  remained  attached. 
Excluded  portion  of  large  intestine  empty  and  contracted.  Rectum  contained 
a  small  quantity  of  fluid  fasces. 

5,     Colo-Rectostomy. 

Amon°"  the  many  possibilities  in  the  operative  treatment  of 
intestinal  obstruction,  a  condition  might  be  met  with  where  the  seat 
of  obstruction  is  located  low  down  in  the  colon,  perhaps  in  the  sig- 
moid flexure,  and  where  it  might  be  impossible  or  impracticable  to 
remove  the  cause  of  obstruction,  and  where  it  becomes  necessary 
to  restore  the  continuity  of  the  intestinal  canal  by  establishing  a 
communication  between  the  permeable  portion  of  the  colon  and  the 
rectum.  Such  an  anastomosis  can  be  made,  as  in  ileo-colostomy,  by 
lateral  implantation,  lateral  apposition  by  perforated  approximation 
plates,  or  by  double  suturing.  For  want  of  time  only  one  experiment 
was  made,  and  although  the  animal  died  from  the  immediate  effects 
of  the  operation,  the  local  conditions  at  the  site  of  operation  found 
after  death  showed  that  colo-rectostomy  in  selected  cases  is  not  only 
a  justifiable  and  feasible  operation,  but  whenever  it  can  be  done,  that 
it  is  always  preferable  to  the  formation  of  an  artificial  anus.  As  the 
operation  by  lateral  apposition  requires  much  less  time  than  lateral 
implantation,  it  should  be  preferred  to  the  latter  procedure,  and 
should  be  done  by  perforated  approximation  discs  and  a  few  super- 
ficial sutures. 

Experiment  92.  Medium-sized  cat.  Incision  through  thelinea  alba;  colon 
cut  transversely  in  the  middle  third  and  the  distal  portion,  and  the  rectum 
cleared  of  its  contents  by  injecting  a  stream  of  warm  water  from  the  cut  end 
downward,  a  procedure  which  could  only  be  well  accomplished  after  forcible 


ADHESION  EXPERIMENTS.  157 

dilatation  of  the  sphincter  ani  muscles.  The  distal  end  was  closed  in  the 
usual  manner.  The  rectum  was  drawn  upward  and  an  incision  made  into  its 
anterior  wall  large  enough  to  correspond  with  the  lumen  of  the  colon.  Into 
this  opening  the  proximal  end  of  the  colon  was  implanted  by  two  rows  of 
futures.  During  the  latter  part  of  the  operation,  winch  lasted  over  an  hour, 
the  animal  was  seized  by  convulsions  which  continued  for  several  hours,  and 
finally  subsided  under  the  administration  of  whisky  given  hypodermically. 
The  symptoms  of  shock,  however,  continued  and  death  occurred  thirty  sis 
hours  after  operation.  Numerous  omental  adhesions;  closed  end  of  bowel 
congested;  peritoneal  surfaces  adherent;  colon  and  rectum  at  point  of 
implantation  adherent. 

Remarks. — In  cases  where  the  obstruction  is  located  some  dis- 
tance from  the  rectum,  where  it  would  be  impossible  to  approximate 
the  permeable  portion  of  the  colon  with  the  rectum,  the  entire  colon 
must  be  excluded  and  the  continuity  of  the  intestinal  canal  restored 
by  ileo-colostomy  or  ileo-rectostomy.  In  all  cases  of  intestinal 
anastomosis  where  the  communication  is  made  in  the  lower  portion 
of  the  colon  or  the  rectum,  the  sphincters  of  the  anus  should  be 
rendered  temporarily  incompetent  by  stretching,  for  the  purpose  of 
guarding  against  over- distention  of  this  part  of  the  bowel  during 
the  time  required  for  the  healing  process  between  the  united 
intestines. 

Y.     Adhesion  Experiments. 

In  works  on  abdominal  surgery  we  invariably  meet  with  the 
assertion  that  serous  surfaces  brought  into  apposition  by  suturing 
unite  after  a  few  hours.  Isolated  experiments  and  the  results  of 
post-mortem  examinations  have  given  rise  to  the  general  belief  that 
serous  surfaces  so  united  will  become  firmly  adherent  in  a  very  short 
time;  but  the  question  concerning  the  exact  time  for  adhesion  to 
take  place,  and  for  the  definitive  healing  to  be  complete,  can  only  be 
determined  by  experiments  made  for  this  special  purpose.  The 
following  experiments  were  made  with  a  view  of  ascertaining  the 
exact  time  which  is  requisite  for  adhesions  and  definitive  healing 
between  approximated  serous  surfaces  to  take  place,  and  likewise  to 
shidy  the  effects  of  local  conditions  which  would  hasten  or  retard 
these  processes.  It  is  quite  important  to  make  a  distinction  between 
the  terms  "adhesion"  and  "healing."     Adhesion   precedes  the  pro 

of   definitive  healing,  but    implies   simply  the    present f  an 

adhesive  or  cement  substance  between  the  serous  surfaces,  which 
mechanically  agglutinates  the  parts;  while  definitive  healing  includes 


458  EXPERIMENTAL  SURGERY. 

all  the  processes  which  take  place  during  cicatrization.  In  intestinal 
surgery  this  distinction  has  an  important  practical  bearing,  as  per- 
foration may  take  place  as  long  as  the  serous  surfaces  are  simply 
held  together  by  adhesions,  while  such  an  occurrence  is  beyond  the 
reach  of  all  possibilities  after  the  approximated  surfaces  have 
become  united  by  living  organized  tissue.  Adhesione  between 
serous  surfaces  take  place  by  the  exudation  of  plastic  lymph,  which 
acts  the  part  of  a  cement  material;  while  on  the  other  hand,  the 
process  of  definitive  healing  is  initiated  by  cell-proliferation  from 
the  pre-existing  endothelial  and  connective  tissue  cells,  and  the  for- 
mation of  a  network  of  new  blood-vessels  springing  from  each  of  the 
coaptated  granulating  surfaces.  The  processes  are  the  same  as  we 
observe  within  blood-vessels  during  cicatrization  after  ligature.  In 
suturing  an  intestinal  wound,  or  in  making  a  circular  enterorrhaphy, 
it  has  always  heretofore  been  deemed  necessary  not  to  injure  the 
peritoneum  unnecessarily,  for  fear  that  such  injuries  would  result 
deleteriously  by  interfering  with  the  prompt  union  between  the 
sutured  surfaces. 

It  is  a  well  known  fact  in  surgery  that  approximation  of  intact 
serous  surfaces  does  not  result  in  the  formation  of  adhesions. 
When  the  surgeon  desires  to  secure  union  between  serous  surfaces 
he  resorts  to  mechanical  irritation  for  the  purpose  of  inducing  a 
circumscribed  plastic  peritonitis,  which  invariably  results  in  adhe- 
sions and  the  obliteration  of  the  serous  space.  Reasoning  from 
this  analogy,  I  was  induced  to  study  the  effects  of  traumatic  and 
chemical  irritation  in  hastening  adhesions  and  cicatrization  between 
apposed  serous  surfaces.  In  most  of  these  experiments  the  serous 
surfaces  in  the  different  operations  were  held  in  contact  by  perfor- 
ated approximation  plates,  and  in  case  artificial  means  were 
employed  to  expedite  the  healing  process,  the  fact  is  mentioned, 
and  the  result  of  such  modification  noted.  The  animals  operated 
on  were  all  dogs. 

I.     Traumatic  Irritation  of  Serous  Surfaces. 

Time,  Six  Houbs. 

Experiment  93.  The  ileum  was  divided  near  the  middle,  and  both  ends 
closed  by  invagination  and  the  continued  suture.  Ileo-ileostomy  was  made 
at  two  points,  making  two  openings  of  communication.  No  suturing.  Parts 
kept  in  apposition  by  perforated  decalcified  bone  plates.  To  compare  the 
effect  of  traumatic  irritation  of  the  peritoneum  in  the  reparative  process 


TRAUMATIC  IRRITATION   OF  SEROUS  SURFACES.  459 

with  the  intact  serous  surface,  the  peritoneal  surfaces  at  one  point  of  opera- 
tion designated  as  the  upper,  were  scarified  with  the  point  of  a  needle  over  an 
area  corresponding  to  the  size  of  the  bone  discs,  the  scratches  being  made 
sufficiently  deep  to  penetrate  the  entire  thickness  of.  the  peritoneum.  The 
scarifications  were  made  in  a  longitudinal  and  transverse  direction,  mapping 
out  the  serous  surfaces  into  small  squares.  Only  slight  oozing  followed  this 
procedure.  The  serous  surfaces  between  the  plates  at  No.  1,  where  no  scarifi- 
cation was  made,  was  found  slightly  adherent  by  a  scanty  deposit  of  plastic 
lymph.  At  No.  2,  where  scarifications  had  been  done,  the  amount  of  plastic 
lymph  was  greater  and  stained  by  blood,  and  the  adhesions  much  firmer. 

Time,  Twelve  Houes. 

Experiment  94.  In  this  experiment  the  bowel  was  not  interrupted  by 
division,  but  two  adjacent  coils  of  the  ileum  were  united  by  making  an  ileo- 
ileostomy  by  perforated  decalcified  bone  plates,  the  plates  holding  the  parts 
perfectly  in  apposition;  a  slight  tumefaction  of  the  intestinal  walls  made  the 
coaptation  more  secure.  Coaptated  serous  surfaces  very  vascular,  covered 
with  a  thin  layer  of  plastic  lymph  which  had  agglutinated  the  folds  of  the 
intestine  brought  in  contact. 

Experiment  95.  Bowel  not  divided,  but  two  adjoining  loops  of  the  ileum 
united  by  making  a  double  ileo-ileostomy  by  perforated  approximation  discs, 
the  two  communicating  openings  about  six  inches  apart.  At  one  point  of 
operation,  designated  as  No.  2,  serous  surfaces  freely  scarified.  At  both 
points  the  adhesions  were  perfect  throughout,  but  where  scarification  was 
made  they  were  notably  firmer. 

Experiment  96.  In  this  experiment  a  gastroenterostomy  and  an  ileo- 
ileostomy  were  made  at  the  same  time  and  on  the  same  animal.  In  both 
operations  the  parts  were  coaptated  by  perforated  decalcified  bone  plates. 
Scarification  of  peritoneal  surfaces  at  both  places.  The  adhesions  between 
the  anterior  surface  of  the  stomach  and  upper  portion  of  jejunum  were 
uniform  throughout,  over  the  whole  surface,  kept  in  contact  by  the  plates. 
There  was  no  leakage  on  distending  the  stomach  and  intestine  forcibly  by 
water.  The  adhesions  between  the  folds  of  the  ileum  at  point  of  approxima- 
tion were,  if  anything,  firmer  than  between  stomach  and  jejunum.  The 
decalcified  bone  plate  in  the  interior  of  the  stomach  was  softened  more  than 
those  in  the  intestine. 

Time,  Eighteen  Homes. 

Experiment  97.  Gastroenterostomy  by  perforated  decalcified  bone 
plates;  communication  made  between  stomach  and  upper  portion  of  jejunum; 
no  scarification.  Agglutination  quite  firm,  so  that  forcible  distention  of 
stomach  and  bowel  caused  no  leakage.  New  opening  sufficiently  large  to 
admit  middle  finger,  and  apparently  lined  throughout  by  mucous  membrane. 
Plate  in  stomach  very  much  softened  and  on  the  verge  of  becoming  detached. 
On  forcibly  separating  the  adhesions  the  serous  surfaces  were  found  to  be 
cemented  together  by  a  thin  layer  of  plastic  lymph,  and  after  scraping  this 
away  they  appeared  vascular  and  rough,  as  though  completely  deprived  of  the 
endothelial  covering. 


460  EXPERIMENTAL  SURGERY. 

Time,  Twenty-foub  Houes. 

Experiment  98.  Triple  ileo-ileostomy  without  division  of  the  bowel ;  the 
operations  were  numbered  1,  2,  3,  respectively.  Coaptation  by  approxima- 
tion discs  of  decalcified  bone.  Communicating  openings  about  six  inches 
apart.  In  No.  1  no  scarification.  No.  2,  scarification  of  one  loop  only.  No. 
3,  scarification  of  both  serous  surfaces.  After  twenty-four  hours  the  result 
was  as  follows  : 

No.  1.     Lymph  scanty;  adhesions  not  very  firm. 

No.  2.     Lymph  more  plentiful ;  adhesions  firmer. 

No.  3.  Lymph  more  abundant  than  in  No.  2,  and  mixed  with  a  fine 
stratum  of  coagulated  blood  ;  adhesions  also  firmer.  The  adhesions  increase 
in  firmness  in  the  qrder  1,  2,  3. 

Experiment  99.  Double  gastro-enterostomy  by  perforated  decalcified 
bone  plates.  The  communicating  openings,  one  near  the  pyloric,  and  the  other 
near  the  cardiac  extremity  of  the  stomach,  were  made  between  the  anterior 
surface  of  the  stomach,  and  the  upper  portion  of  the  jejunum.  In  operation 
No.  1,  the  intact  serous  surfaces  near  the  pylorus  were  brought  in  contact, 
while  in  the  second  operation  both  the  stomach  and  bowel  were  scarified.  At 
the  post-mortem,  it  was  found  that  the  adhesions  at  both  places  were  of 
sufficient  firmness  to  prevent  leakage  under  pressure.  In  No.  2,  adhesions 
firmer  and  the  inflammatory  infiltration  more  marked  than  in  No.  1.  Plates 
in  stomach  much  softened,  but  remain  in  situ.  Openings  lined  throughout 
by  mucous  membrane  and  sufficiently  large  to  admit  the  index  finger. 

Experiment  100.  Ileo-colostomy  by  lateral  apposition  and  fixation  by 
perforated  approximation  discs.  Lower  portion  of  ileum  united  with  the 
ascending  colon.  No  scarification  ;  bowels  lightly  agglutinated  throughout 
by  a  very  thin  layer  of  plastic  lymph  ;  adhesions,  however,  could  be  easily 
separated,  and  where  this  is  done  the  peritoneal  surface  appeared  denuded  of 
endothelial  cells,  and  very  vascular  with  new  vessels  along  the  outer  margin 
of  the  surface  of  approximation. 

Time,  Foety-eight  Hotjbs. 

Experiment  101.  Double  gastro-enterostomy.  The  communicating  open- 
ings were  between  the  anterior  surface  of  the  stomach  and  the  duodenum,  and 
the  posterior  surface  of  the  stomach  and  the  upper  portion  of  the  jejunum. 
In  the  posterior  operation  the  intact  serous  surfaces  were  brought  in  contact, 
while  in  the  anterior,  the  peritoneal  surfaces  of  the  stomach  and  duodenum 
were  scarified.  In  both  operations  perforated  decalcified  bone  plates  were 
used.  Adhesions  between  posterior  surface  of  stomach  and  bowel  uniform 
throughout,  but  easily  broken  down;  the  peritoneal  surfaces  injected  and 
apparently  deprived  of  their  endothelial  covering.  The  anterior  operation 
resulted  in  the  formation  of  firm  adhesions,  the  products  of  exudation  and 
tissue  proliferation  being  supplied  with  new  vessels,  the  circumscribed  plastic 
peritonitis  being  much  more  advanced  than  at  the  site  of  the  posterior 
operation. 


CHEMICAL   IRRITATION    OF  SEROUS  SURFACES.  461 

Experiment  102.  Double  ileo-colostomy  by  perforated  approximation 
plates.  The  anastomosis  between  the  lower  portion  of  the  ileum  and  the 
colon  just  above  the  cascum  was  made  without  scarification,  while  in  the  second 
operation  about  six  inches  higher  up  in  the  colon  and  ileum,  both  serous 
surfaces  were  freely  scarified.  Omentum  adherent  at  point  of  operation. 
Plates  swollen,  softened  and  pliable,  but  still  efficient  in  maintaining  coapta- 
tion and  fixation.  Adhesions  at  both  places  quite  firm,  but  more  so  in  the 
upper  portion  where  scarification  had  been  done. 

Experiment  103.  Ileo-colostomy  by  approximation  discs.  The  ileum  was 
divided  a  few  inches  above  the  ileo-caecal  region,  and  both  ends  closed  by 
invagination  and  three  stitches  of  the  continued  suture.  An  anastomosis  was 
made  between  the  proximal  end  and  the  ascending  colon  by  lateral  apposition. 
No  scarification.  Intestines  agglutinated  at  point  of  operation,  but  the 
adhesions  gave  way  when  the  bowel  was  forcibly  distended  under  hydrant 
pressure. 

2.     Chemical  Irritation  of  Serous  Surfaces. 

In  these  experiments  it  was  aimed  to  study  the  effect  of 
chemical  irritation  of  the  peritoneum  in  the  reparative  process  after 
intestinal  operations.  Iodine  has  been  used  for  a  long  time  in  pro- 
ducing plastic  inflammation  of  serous  surfaces  for  the  purpose  of 
obliterating  serous  cavities,  consequently  this  substance  was  used  in 
the  first  experiments.  To  study  the  effects  of  the  diffuse  application 
of  tincture  of  iron  to  the  intact  peritoneal  cavity,  the  following 
experiments  were  made: 

Experiment  104.  Medium-sized  dog.  The  needle  of  a  hypodermic  syringe 
was  thoroughly  disinfected,  and  a  drachm  of  the  tincture  of  iodine  injected 
into  the  peritoneal  cavity.  Immediately  after  the  injection  the  animal 
evinced  great  pain,  which,  however,  appeared  to  subside  after  a  short  time, 
and  subsequently  no  unfavorable  symptoms  were  observed.  Three  days  after 
the  injection  the  urine  was  examined  and  showed  the  presence  of  iodine. 
Dog  killed  nine  days  after  the  injection.  Circumscribed  plastic  peritonitis 
over  a  space  four  inches  square,  corresponding  to  the  point  where  the 
puncture  was  made.  At  this  place  the  omentum  was  much  thickened,  very 
vascular  and  adherent  to  the  parietal  peritoneum  and  the  adjoining  folds  of 
the  intestines. 

Experiment  10~>.  Medium-sized  dog.  A  fluid  drachm  of  the  tincture  of 
muriate  of  iron  was  thrown  into  the  peritoneal  cavity  by  means  of  a  well- 
disinfected  hypodermic  syringe.  The  pain  immediately  after  the  injection  was 
intense,  and  the  animal  appeared  to  be  very  ill  two  days  after  the  injection, 
and  died  with  well-marked  symptoms  of  peritonitis  on  the  sixth  day.  Diffuse 
plastic  peritonitis  was  found  to  be  the  cause  of  death.  The  omentum  was 
adherent  everywhere,  and  the  intestines  were  matted  together  by  numerous 
adhesions.  The  abdominal  cavity  contained  a  considerable  quantity  of  serous 
fluid. 


46'^  *  EXPERIMENTAL  SURGERY. 

Remarks. — Both  experiments  prove  that  when  tincture  of  iodine 
and  tincture  of  iron  are  brought  in  contact  with  the  peritoneum,  a 
plastic  inflammation  ensues ;  and  it  was  reasonable  to  expect  that  if 
either  of  these  substances  could  be  applied  to  the  serous  surfaces 
which  it  was  intended  to  unite,  the  reparative  process  would  be 
hastened. 

Experiment  106.  Triple  ileo-ileostomy  by  perforated  decalcified  bone 
plates.  Three  internal  fistulas  were  made  between  the  adjacent  loops  of  the 
ileum,  about  six  inches  apart.  In  operation  No.  1,  approximation  of  intact 
serous  surfaces;  in  operation  No.  2,  the  serous  surfaces  were  painted  with 
tincture  of  iron  over  an  area  corresponding  to  the  size  of  the  plates;  in  oper- 
ation No.  3,  the  serous  surfaces  over  the  same  extent  were  brushed  with  pure 
tincture  of  iodine.  The  animal  was  killed  forty-eight  hours  after  operation, 
and  the  following  conditions  were  noted:  No  general  peritonitis.  All  the  plates 
firmly  in  place  coaptating  the  serous  surfaces  accurately,  the  swelling  of  the 
tunics  of  the  bowel  only  serving  to  enhance  their  efficiency.  At  No.  1,  adhe- 
sions quite  firm,  flexion  of  bowel  and  marked  injection  of  serous  surfaces.  At 
No.  2,  no  adhesions  between  serous  surfaces.  The  peritoneal  surfaces  to  which 
the  tincture  of  iron  had  been  applied  appeared  stained,  almost  black,  and  at 
some  points  the  serous  coat  was  destroyed.  At  No.  3,  peritoneal  surfaces 
stained  dark  brown;  adhesions  firm,  and  an  abundance  of  plastic  lymph  even 
beyond  the  margin  of  the  plates. 

Experiment  107.  Double  ileo-ileostomy  by  approximation  plates  and 
omental  grafting.  Operation  No.  1,  approximation  of  ileum  to  ileum  by  per- 
forated decalcified  bone  plates;  serous  surfaces  intact.  Operation  No.  2, 
similar  operation  six  inches  higher  up  uniting  the  same  loops,  but  painting 
the  serous  surfaces  with  pure  tincture  of  iodine.  Operation  3,  cutting  off  a 
piece  of  omentum  two  inches  wide  and  sufficiently  long  to  encircle  the  entire 
bowel.  After  scarifying  the  bowel  and  the  omental  graft  on  one  side,  the 
scarified  surfaces  were  brought  in  contact,  and  the  graft  fixed  in  its  place  by 
two  fine  catgut  sutures  passed  through  the  mesentery  and  both  ends  of  the 
graft.  Animal  killed  forty-eight  hours  after  operation.  All  plates  firmly  in 
place.  At  No.  1,  adhesions  firm.  At  No.  2,  dark-brown  discoloration  of  surface 
to  which  the  iodine  had  been  applied;  agglutination  over  the  whole  surface. 
Under  hydrostatic  pressure  the  adhesions  first  gave  way  between  the  two 
plates  where  the  iodine  had  been  applied;  showing  conclusively  that  chemical 
irritation  of  serous  surfaces  does  not  hasten  the  adhesive  process,  while  it  may, 
and  probably  does,  expedite  the  definitive  healing.  At  No.  3,  omental  graft 
firmly  adherent  to  the  entire  circumference  of  the  bowel,  and  beginning 
vascularization  of  the  graft  around  its  margins. 

Remarks. — In  all  of  these  experiments  the  post-mortem  exami- 
nations showed  no  evidences  of  diffuse  peritonitis.  In  most  of  the 
cases  the  inflammatory  process  was  limited  to  the  portion  of 
the  bowel  interposed  between  the  plates.     Without  exception  the 


OMENTAL   GRAFTING.  *  463 

i 

adhesions  formed  were  firmest  and  the  definitive  healing  was 
initiated  first  where  scarification  was  performed ;  results  which  clearly 
demonstrate  the  fact  that  the  reparative  process  between  serous  sur- 
faces which  it  is  intended  to  unite,  is  hastened  by  traumatic  irritation. 
Traumatic  irritation  by  scarification  of  the  peritoneal  surface  with 
the  point  of  an  aseptic  needle,  is  the  most  potent  means  to  provoke 
a  circumscribed  plastic  peritonitis,  and  is  followed  within  a  few 
hours  by  a  copious  exudation  of  plastic  lymph,  which,  like  a  cement 
substance,  mechanically  agglutinates  the  coaptated  serous  surfaces. 
The  same  measure,  by  destroying  the  continuity  of  the  non-vascular 
layer  of  the  peritoneum,  brings  at  once  in  contact  the  vascular  net- 
work of  both  sides  of  the  bowel,  and  opens  up  a  direct  route  for  the 
new  vessels,  an  important  element  in  the  rapid  healing  of  the  visceral 
wounds.  Chemical  irritants  by  destroying  the  endothelial  layer  of 
the  peritoneum  rather  retard,  than  favor,  early  adhesion  and  union 
between  the  coaptated  bowels,  and  should  therefore  not  be  resorted 
to  in  intestinal  surgery,  to  hasten  the  reparative  process. 

3.     Omental   Grafting. 

Under  the  head  of  circular  enterorrhaphy,  mention  is  made  of 
transplantation  of  omental  flaps  after  uniting  the  two  ends  of  the 
bowel  by  suturing  or  invagination,  with  a  view  of  securing  an  addi- 
tional safeguard  against  perforation  during  the  process  of  repair.  A 
number  of  experiments  are  described  where  the  procedure  was  prac- 
ticed with  satisfactory  results.  After  a  few  days  the  omental  flaps 
were  found  firmly  adherent  and  vascular  around  the  whole  circum- 
ference of  the  bowel,  constituting  a  ring  of  living  tissue  outside  the 
line  of  suturing.  In  all  these  cases  the  proximal  end  of  the  flap 
remained  in  connection  with  the  omentum,  and  care  was  taken  to  cut 
the  flap  in  such  a  manner  that  some  vessel  of  considerable  §ize  should 
furnish  the  necessary  vascular  supply.  I  was  well  aware  that  plaus- 
ible objections  could  be  entered  against  this  method,  in  that  the 
connecting  bridge  between  the  bowel  and  the  omentum  might  become 
subsequently  a  cause  of  intestinal  obstruction  by  making  traction 
upon  the  bowel,  thus  causing  a  flexion,  or,  by  becoming  a  band  of 
constriction  for  some  loop  of  intestine. 

For  the  purpose  of  obviating  such  remote  consequences  I 
resorted  to  another  procedure  which  I  have  designated  as  omental 
grafting.     I  was  familiar  with  the  fact  that  implantations  of  aseptic 


464  •  EXPERIMENTAL  SURGERY. 

4 

substances  into  the  peritoneal  cavity  had  frequently  been  done 
without  any  immediate  or  remote  ill -effects,  and  I  had  every  reason 
to  expect  that  a  large,  completely  detached,  aseptic,  omental  graft, 
in  an  aseptic  abdominal  cavity,  would  be  well  tolerated,  and  would 
soon  become  adherent  to  the  subjacent  peritoneal  surface,  and  thus 
afford  an  additional  safeguard  against  perforation  and  the  disastrous 
consecutive  result,  namely :  perforative  peritonitis  during  the  time 
required  for  the  healing  of  the  intestinal  wound.  In  the  following 
experiments  the  grafts  used  were  from  one  and  a  half  to  two  inches 
in  width,  and  of  sufficient  length  to  completely  encircle  the  bowel. 
The  free  ends  were  made  to  project  a  few  lines  beyond  the  mesen- 
teric attachment,  and  were  fixed  by  two  fine  catgut  sutures,  each  of 
which  embraced  the  corresponding  angles  of  the  graft  and  the 
mesentery.  The  stitches  were  made  in  the  direction  of  the  mesen- 
teric vessels,  so  that  in  tying,  no  vessels  should  be  included  in  the 
suture.     In  these  experiments  dogs  were  used  exclusively. 

Experiment  108.  Three  pieces  of  omentum,  two  inches  wide  and  sum 
ciently  long  to  encircle  the  bowel,  were  completely  detached  and  grafted  as 
follows : 

1.  Graft  simply  laid  over  the  bowel  corresponding  to  the  lower  portion 
of  the  ileum,  and  fastened  in  its  place  on  mesenteric  side  by  two  fine  catgut 
sutures. 

2.  Serous  surface  of  bowel  about  six  inches  higher  up  scarified,  and  graft 
applied  to  this  surface  and  fixed  in  the  same  manner. 

3.  Bowel  treated  in  the  same  way  about  six  inches  still  higher  up,  and 
one  of  the  serous  surfaces  of  the  graft  also  freely  scarified. 

The  graft  was  scarified  on  the  side  which  was  to  be  brought  in  contact 
with  the  bowel.  Fixation  of  graft  by  two  catgut  sutures  on  mesenteric  side. 
Animal  killed  thirty-six  hours  after  operation.  All  the  grafts  adherent, 
slightly  contracting  the  bowel  at  the  three  different  places.  On  separating 
the  adhesions  the  subjacent  serous  surface  very  vascular  and  denuded  of  its 
endothelial  layer.  Firmness  of  adhesions  increased  in  proportion  to  the 
extent  of  scarification  done,  being  least  firm  at  No.  1,  firmer  at  No.  2,  and 
firmest  at  No.  3,  where  both  coaptated  serous  surfaces  had  been  scarified.  At 
Nos.  2  and  3,  the  plastic  lymph  was  freely  supplied  with  new  blood-vessels. 
The  vascularization  was  most  conspicuous  on  the  mesenteric  side. 

Experiment  109.  Two  omental  grafts  planted  around  the  ileum  in  the 
same  manner  as  described  above.  At  No.  1,  both  the  bowel  and  the  inner  side 
of  the  graft  were  scarified;  at  No.  2,  only  the  serous  surface  of  the  bowel. 
Animal  killed  forty-three  hours  after  operation.  Stump  of  omentum  adherent 
to  abdominal  wound  and  intestines.  No  peritonitis.  At  No.  1,  graft  firmly 
adherent  over  the  entire  extent.  A  slight  extravasation  of  blood  between  the 
graft  and  the  bowel.     Beginning  vascularization  of  interposed  plastic  lymph. 


OMENTAL   GRAFTING.  465 

At  No.  2,  also  firm  adhesions  and  beginning  vascularization  of  the  plastic 
exudation.  Both  of  the  grafts  appear  to  be  stained  with  the  coloring  material 
of  the  blood. 

Experiment  110.  Planting  of  two  omental  grafts  around  the  ileum  about 
eight  inches  apart.  At  No.  1,  both  the  bowel  and  one  side  of  the  omental 
graft  were  scarified.  At  No.  2,  only  the  serous  surface  of  the  bowel  was  treated 
in  this  manner.  Animal  killed  six  days  after  the  operation.  Both  grafts 
firmly  adherent  throughout  and  freely  supplied  with  blood-vessels,  the  largest 
of  the  new  vessels  being  on  the  mesenteric  side.  The  omental  stump  adherent 
to  the  portion  of  bowel  between  the  grafts  where  a  flexion  had  been  made  from 
this  cause. 

Experiment  111.  In  this  experiment  omental  grafting  was  done  at  two 
points  around  the  lower  portion  of  the  ileum.  At  one  point  the  serous 
surfaces  were  left  intact,  at  the  other,  both  the  peritoneal  surface  of  the  bowel 
and  the  omental  graft  were  freely  scarified.  Animal  remained  perfectly  well 
and  was  killed  eight  days  after  operation.  No  signs  of  peritonitis.  Both 
grafts  formed  a  thin  vascular  layer  around  the  entire  circumference  of 
the  bowel,  and  firmly  and  evenly  united  throughout.  Vascularization  was 
more  marked  where  scarification  had  been  done.  On  attempting  to  separate 
the  grafts  it  was  difficult  to  find  and  define  the  line  of  union  between  the 
omentum  and  the  underlying  bowel,  as  the  union  was  very  intimate  and  firm. 

Kemarks. — In  all  of  these  experiments  the  grafts  retained  their 
vitality,  and  in  a  few  hours  became  firmly  adherent  to  the  intestinal 
surface  with  which  they  had  been  brought  in  contact.  Scarification 
of  the  serous  surface  has  also  been  found  in  these  experiments,  an 
exceedingly  valuable  measure  in  hastening  the  processes  of  adhesion, 
granulation  and  vascularization.  By  planting  grafts  side  by  side, 
with  and  without  scarification,  I  was  enabled  to  determine  with 
accuracy  the  beneficial  influence  exerted  by  this  procedure  in  favor- 
ing the  reparative  process,  and  without  a  single  exception,  observed 
that  where  scarification  was  done  the  adhesions  were  firmer  and 
vascularization  more  advanced.  The  post-mortem  examinations 
appeared  to  demonstrate  that  the  firmness  of  the  adhesions  and  the 
degree  of  vascularization  wore  in  direct  proportion  to  the  extent  of 
traumatic  irritation  of  the  peritoneum,  being  always  most  marked  in 
cases  where  both  the  bowel  and  the  under  surface  of  the  graft  were 
scarified,  and  least  where  intact  peritoneal  surfaces  were  brought  into 
apposition. 

As  soon  as  the  omental  grafts  were  cut  off  from  the  omentum 
they  were  placed  in  a  1-2000  solution  of  corrosive  sublimate,  kept 
at  the  temperature  of  the  body,  in  order  to  secure  for  tho  graft  a 
perfectly  aseptic   condition   until    everything  was    in  readiness  for 


466  EXPERIMENTAL  SURGERY. 

the  transfer  of  the  graft  to  its  new  location.  Before  planting  the 
graft  it  was  carefully  dried  by  pressing  it  between  gauze  or  sponges 
wrung  out  of  the  same  solution.  The  scarifications  of  the  serous 
surfaces  should  only  be  made  sufficiently  deep  to  give  rise  to  a  very 
slight  oozing,  as  when  haemorrhage  is  more  profuse,  there  is  danger 
of  the  formation  of  a  clot  between  the  graft  and  the  bowel,  which,  if 
it  does  not  ultimately  prevent  union  between  the  coaptated  surfaces, 
must  necessarily  interfere  with  the  formation  of  early  and  firm 
adhesions. 

Omental  grafting  cannot  fail  to  become  an  established  proced- 
ure in  many  abdominal  operations.  After  suturing  a  large  wound 
of  the  stomach  or  intestines,  a  strip  of  omentum  should  be  laid 
over  the  wound  and  fastened  in  its  place  by  a  few  catgut  sutures. 
After  circular  enterorrhaphy,  the  operation  should  be  finished  by 
covering  the  circular  wound  by  an  omental  graft  about  two  inches 
wide,  which  should  be  fixed  in  its  place  by  two  catgut  sutures  passed 
through  both  ends  of  the  graft  and  the  mesentery.  Omental  graft- 
ing should  also  be  resorted  to  in  repairing  peritoneal  defects  in 
visceral  injuries  of  the  abdominal  organs,  and  in  covering  large 
stumps  after  ovariotomy  or  hysterectomy,  where  the  pedicle  is 
treated  by  the  intra-abdominal  method. 

VI.    Conclusions. 

In  conclusion  I  beg  leave  to  submit  the  following  propositions 
for  further  discussion  : 

1.  Traumatic  stenosis  from  partial  enterectomy  and  longitu- 
dinal suturing  of  the  wound  becomes  a  source  of  danger  from 
obstruction  or  perforation,  in  all  cases  where  the  lumen  of  the  bowel 
is  reduced  more  than  one-half  in  size. 

2.  Longitudinal  suturing  of  wounds  on  the  mesenteric  side  of 
the  intestine  should  never  be  practiced,  as  such  a  procedure  is 
invariably  followed  by  gangrene  and  perforation  by  intercepting  the 
vascular  supply  to  the  portion  of  bowel  which  corresponds  to 
the  mesenteric  defect. 

3.  The  immediate  cause  of  gangrene  in  circular  constriction  of 
a  loop  of  intestine  is  due  to  obstruction  of  the  venous  circulation, 
and  takes  place  first  in  the  majority  of  cases  at  a  point  most  remote 
from  the  cause  of  the  obstruction. 


CONCLUSIONS.  467 

4.  On  the  convex  surface  of  the  bowel  a  defect  an  inch  in 
width,  from  injury  or  operation,  can  be  closed  by  transverse  suturing 
without  causing  obstruction  by  flexion.  In  such  cases  the  stenosis 
is  subsequently  corrected  by  a  compensating  bulging  or  dilatation 
of  the  mesenteric  side  of  the  bowel. 

5.  Closing  a  wound  of  such  dimensions  on  the  mesenteric  side 
of  the  bowel  by  transverse  suturing  may  give  rise  to  intestinal 
obstruction  by  flexion,  and  to  gangrene  and  perforation  by  seriously 
impairing  the  arterial  supply  to,  and  venous  return  from,  the  portion 
of  bowel  corresponding  with  the  mesenteric  defect. 

6.  Flexion  caused  by  inflammatory  and  other  extrinsic  causes 
gives  rise  to  intestinal  obstruction  only  in  case  the  functional 
capacity  of  the  flexed  portion  of  the  bowel  has  been  impaired  or 
suspended  by  the  causes  which  have  produced  the  flexion,  or  by 
subsequent  pathological  conditions  which  have  occurred  independ- 
ently of  the  flexion. 

7.  As  in  flexion,  a  volvulus  gives  rise  to  symptoms  of  obstruc- 
tion, when  the  causes  which  have  given  rise  to  a  rotation  upon  its 
axis  of  a  loop  of  bowel  have  at  the  same  time  produced  an  impair- 
ment or  suspension  of  peristalsis  in  the  portion  of  bowel  which 
constitutes  the  volvulus;  or  when  a  diminution  or  suspension  of 
peristalsis  follows  in  consequence  of  the  degree  or  extent  of  the 
rotation. 

8.  Accumulation  of  intestinal  contents  above  the  seat  of  in- 
vagination is  one  of  the  most  important  factors  which  prevents 
spontaneous  reduction,  and  which  determines  gangrene  of  the 
intussusceptum  and  perforation  of  the  bowel. 

9.  Spontaneous  disinvagination  is  not  more  frequent  in  ascend- 
ing than  descending  invagination. 

10.  The  immediate  or  direct  cause  of  gangrene  of  the  intus- 
susceptum is  obstniction  to  the  return  of  venous  blood  by  constric- 
tion at  the  neck  of  the  intussuscipiens. 

11.  Ileo-csecal  invagination,  when  recent,  can  frequently  be 
reduced  by  distention  of  the  colon  and  rectum  with  water;  but  this 
method  of  reduction  must  be  practiced  with  the  greatest  caution  and 
gentleness,  as  over-distention  of  the  colon  and  rectum  is  productive 
of  multiple  longitudinal  lacerations  of  the  peritoneal  coat,  an  acci- 
dent which  is  followed  by  the  gravest  consequences. 


468  EXPERIMENTAL  SURGERY. 

12.  The  competency  of  the  ileo-ctecal  valve  can  only  be  over- 
come by  over-distention  of  the  caecum,  and  is  effected  by  a  mechanical 
separation  of  the  margins  of  the  valve;  consequently  it  is  imprudent 
to  attempt  the  treatment  of  intestinal  obstruction  beyond  the  ileo- 
cecal region  by  injections  per  rectum. 

13.  Resection  of  more  than  six  feet  of  the  small  intestine  in 
dogs  is  uniformly  fatal;  the  cause  of  death  in  such  cases  is  always 
attributable  to  the  immediate  effects  of  the  trauma. 

14.  Resection  of  more  than  four  feet  of  the  small  intestine  in 
dogs  is  incompatible  with  normal  digestion,  absorption  and  nutrition, 
and  often  results  in  death  from  marasmus. 

15.  In  cases  of  extensive  intestinal  resection,  the  remaining 
portion  of  the  intestinal  tract  undergoes  compensatory  hypertrophy, 
which  microscopically  is  apparent  by  thickening  of  the  intestinal 
coats  and  increased  vascularization. 

16.  Physiological  exclusion  of  an  extensive  portion  of  the 
intestinal  tract  does  not  impair  digestion,  absorption  and  nutrition 
as  seriously  as  the  removal  of  a  similar  portion  by  resection. 

17.  Faecal  accumulation  does  not  take  place  in  the  excluded 
portion  of  the  intestinal  canal. 

18.  The  excluded  portion  of  the  bowel  undergoes  progressive 
atrophy. 

19.  A  modification  of  Jobert's  invagination  suture  by  lining 
the  intussusceptum  with  a  thin  flexible  rubber  ring,  and  the  substitu- 
tion of  catgut  for  silk  sutures  is  preferable  to  circular  enterorrhaphy 
by  the  Czerny  Lembert  suture. 

20.  The  line  of  suturing,  or  neck  of  intussuscipiens,  should  be 
covered  by  a  flap  or  graft  of  omentum  in  all  cases  of  circular  resec- 
tion, as  this  procedure  furnishes  an  additional  protection  against 
perforation. 

21.  In  circular  enterorrhaphy,  the  continuity  of  the  peritoneal 
surface  of  the  ends  of  the  bowel  to  be  united  should  be  procured 
where  the  mesentery  is  detached,  by  uniting  the  peritoneum  with  a 
fine  catgut  suture  before  the  bowel  is  sutured,  as  this  modification 
of  the  ordinary  method  furnishes  a  better  security  against  perfora- 
tion on  the  mesenteric  side. 

22.  In  cases  of  complete  division  of  an  intestine,  if  it  is 
deemed  advisable  not  to  resort  to  circular  enterorrhaphy,  one  or  both 


CONCLUSIONS.  469 

ends  of  the  bowel  should  be  closed  by  invagination  to  the  depth  of 
an  inch,  and  three  stitches  of  the  continued  suture  embracing  only 
the  peritoneal  and  muscular  coats. 

23.  The  formation  of  a  fistulous  communication  between  the 
bowel  above  and  below  the  seat  of  the  obstruction  should  take 
the  place  of  resection  and  circular  enterorrhaphy  in  all  cases  where  it 
is  impossible  or  impracticable  to  remove  the  cause  of  obstruction,  or 
where  after  excision  it  would  be  impossible  to  restore  the  continuity 
of  the  intestinal  canal  by  suturing,  or  where  the  pathological  condi- 
tions which  gave  rise  to  the  obstruction  do  not  constitute  an  intrinsic 
source  of  danger. 

24.  The  formation  of  an  artificial  anus  in  the  treatment  of 
intestinal  obstructions  should  be  practiced  only  in  cases  where  con- 
tinuity of  the  intestinal  canal  cannot  be  restored  by  making  an 
intestinal  anastomosis. 

25.  Gastroenterostomy,  jejuno- ileostomy  and  ileo-ileostomy 
should  always  be  made  by  lateral  apposition  with  partially  or  com- 
pletely decalcified  perforated  bone  plates. 

26.  In  making  an  intestinal  anastomosis  for  obstruction  in  the 
caecum,  or  colon,  the  communication  above  and  below  the  seat  of 
obstruction  can  be  established  by  lateral  apposition  with  perforated 
approximation  plates,  or  by  lateral  implantation  of  the  ileum  into 
the  colon  or  rectum. 

27.  An  ileo-colostomy,  or  ileo-rectostomy  by  approximation 
with  decalcified  perforated  bone  plates,  or  by  lateral  implantation, 
should  be  done  in  all  cases  of  irreducible  ileo-caecal  invagination, 
where  the  local  signs  do  not  indicate  the  existence  of  gangrene  or 
impending  perforation. 

28.  In  all  cases  of  impending  gangrene  or  perforation,  the 
invaginated  portion  should  be  excised,  both  ends  of  the  bowel  per- 

iitly  closed,  and  the  continuity  of  the  intestinal  canal  restored 
by  making  an  ileo-colostomy  or  ileo-rectostomy. 

29.  The  restoration  of  the  continuity  of  the  intestinal  canal  by 
perforated  approximation  plates,  or  by  lateral  implantation,  should 
be  resorted  to  in  all  cases  where  circular  enterorrhaphy  is  impossible 
on  account  of  the  difference  in  size  of  the  lumina  of  the  two  ends  of 
the  bowel. 


■170  EXPERIMENTAL  SURGERY. 

30.  In  cases  of  multiple  gunshot  wounds  of  the  intestines 
involving  the  lateral  or  convex  side  of  the  bowel,  the  formation  of 
intestinal  anastomosis  by  perforated  decalcified  bone  plates  should 
be  preferred  to  suturing,  as  this  procedure  is  equally,  if  not  more 
safe,  and  requires  less  time. 

31.  Definitive  healing  of  the  intestinal  wound  is  only  initiated 
after  the  formation  of  a  network  of  new  vessels  in  the  product  of 
tissue  proliferation  from  the  approximated  serous  surfaces. 

32.  Under  favorable  circumstances  quite  firm  adhesions  are 
found  within  the  peritoneal  surfaces  in  six  to  twelve  hours,  which 
effectually  resist  the  pressure  from  within  outward. 

33.  Scarification  of  the  peritoneum  at  the  seat  of  coaptation 
hastens  the  formation  of  adhesions  and  the  definitive  healing  of  the 
intestinal  wound. 

34.  Omental  grafts,  from  one  to  two  inches  in  width,  and 
sufficiently  long  to  completely  encircle  the  bowel,  retain  their  vitality, 
become  firmly  adherent  in  from  twelve  to  eighteen  hours,  and  are 
freely  supplied  with  blood-vessels  in  from  eighteen  to  forty-eight 
hours. 

35.  Omental  transplantation,  or  omental  grafting,  should  be 
done  in  every  circular  resection  or  suturing  of  large  wounds  of 
the  stomach  or  intestines,  as  this  procedure  favors  healing  of  the 
visceral  wound,  and  affords  an  additional  protection  against 
perforation. 


Methods  of  Intestinal  Anastomosis. 


Plate  within  the 
intestine  above 
seat  of  obstruc- 
tion. 


Perforated  de- 
calcified bone- 
plate. 


Intestinal  Anastomosis  ey  Perforated  Decalcified  Bone-Plates. 


Plate  within  colon  below  seat  of 
obstruction. 


Approximation  of  intestine  by 
tying  of  sutures. 


Rubber  ring  within 
bowel  fixed  by  con- 
tinuous catgut  sutures. 


Needles  passed  from 
within  outward  through 
i-iitire  wall  of  bowel  and 
ring. 


Part    to    be    invngi- 
natod. 

Needles    passed 
through     serous      and 

muscular  emits. 


Author's  Modification  of  Jobeet's  Suture. 

471 


RECTAL    INSUFFLATION    OF   HYDROGEN   GAS    AN 
INFALLIBLE   TEST   IN    THE    DIAGNOSIS   OF 
VISCERAL   INJURY    OF    THE    GASTRO- 
INTESTINAL    CANAL     IN     PENE- 
TRATING      WOUNDS        OF 
THE      ABDOMEN. 


The  operative  treatment  of  penetrating  wounds  of  the  abdomen 
complicated  by  visceral  injury  of  the  gastro-intestinal  canal  is  now 
sanctioned  by  the  best  surgical  authorities,  and  may  be  considered 
as  a  well-established  procedure,  based  as  it  is  upon  the  results  of 
experimentation  and  clinical  experience.  A  visceral  wound  of  the 
stomach  or  any  portion  of  the  intestinal  canal  sufficient  in  size  to  give 
rise  to  extravasation  into  the  peritoneal  cavity,  must  be  looked  upon 
as  a  mortal  injury  unless  promptly  treated  by  abdominal  section.  A 
number  of  well  authenticated  cases  are  on  record  where  a  wound  in 
the  stomach  or  the  large  intestine  healed,  and  the  patients  recovered 
without  the  intervention  of  surgery,  but  these  instances  are  so  few 
that,  practically,  the  force  of  the  preceding  statement  remains  unim- 
paired. After  a  careful  study  of  an  immense  amount  of  clinical 
material  Otis  came  to  the  important  conclusion  that  gunshot  injuries 
of  the  small  intestines  under  the  old  expectant  treatment,  without 
exception  resulted  in  death;  and  that  is  a  sufficiently  cogent  argu- 
ment in  favor  of  their  treatment  by  laparotomy  as  affording  the 
only  chance  of  recovery. 

The  great  difficulty  that  presents  itself  to  the  surgeon  in  the 
absence  of  positive  symptoms,  is  the  differential  diagnosis  between  a 
simple  penetrating  wound  and  a  penetrating  wound  complicated  by 
injury  of  the  gastro-intestinal  canal.  While  the  existence  of  serious 
intra-abdominal  haemorrhage  can  usually  be  readily  recognized  by 
well  marked  physical  signs  and  a  coniplexus  of  symptoms  which 
points  to  sudden  diminution  of  intra-arterial  pressure,  and  thus  fur- 
nishes one  of  the  positive   indications  for  treatment  by  laparotomy, 

17:; 


474  EXPERIMENTAL  SURGERY. 

the  well-known  fact  remains  that  a  visceral  injury  of  the  stomach  or 
intestines  seldom  gives  rise  to  symptoms  upon  which  the  surgeon 
could  rely  in  making  a  positive  diagnosis. 

In  the  treatment  of  penetrating  wounds  of  the  abdomen  lapar- 
otomy is  resorted  to  either  (1)  for  the  purpose  of  arresting  danger- 
ous haemorrhage,  or  (2)  for  the  detection  and  treatment  of  a  wound 
or  wounds  of  its  hollow  viscera.  The  first  indication  is  readily 
recognized,  and  the  diagnosis  not  only  justifies  the  operation,  but 
imposes  it  as  a  stern  duty  upon  the  surgeon,  from  which  he  should 
never  shrink.  The  recognition  of  the  second  indication  offers 
greater  difficulties,  and  the  uncertainty  of  diagnosis  which  surrounds 
such  cases  is  used  as  a  sufficient  argument  by  many  in  opposing  the 
adoption  of  timely  and  efficient  surgical  treatment,  and  is  responsi- 
ble for  the  loss  of  many  lives  which  otherwise  might  have  been 
saved.  The  uncertainty  of  diagnosis  must  remain  in  the  way  of  a 
more  general  adoption  of  laparotomy  in  the  treatment  of  penetrating 
wounds  of  the  abdomen,  in  the  case  of  timid  surgeons,  and  the  same 
cause  may  lead  to  most  unpleasant  medico-legal  complications  in 
the  practice  of  bolder  and  more  aggressive  operators. 

Clinical  experience  and  statistics  have  demonstrated  the  impor- 
tance of  making  a  distinction  between  punctured  and  gunshot 
wounds  in  the  abdomen,  both  in  reference  to  diagnosis  and  treat- 
ment. It  is  well  known  that  penetrating  stab -wounds  are  less  likely 
to  be  complicated  by  visceral  injury  than  bullet  wounds,  conse- 
quently this  class  of  injuries  offers  a  more  favorable  prognosis  and 
does  not  call  so  uniformly  for  treatment  by  abdominal  section.  That 
penetrating  gunshot  wounds  of  the  abdomen  do  not  always  implicate 
the  gastro-intestinal  canal  has  been  well  demonstrated  by  experi- 
ment and  clinical  observation.  During  the  last  two  years  three  cases 
of  bullet  wounds  of  the  abdomen  came  under  my  observation  where 
no  doubt  could  be  entertained  that  penetration  had  taken  place,  and 
yet  all  the  patients  recovered  without  operation.  In  all  three  cases 
the  bullet  had  taken  an  antero-posterior  direction.  As  in  private 
practice  the  treatment  of  penetrating  wounds  of  the  abdomen  usually 
involves  great  medico-legal  responsibilities,  it  becomes  of  the 
greatest  importance  to  arrive  at  positive  conclusions  in  reference 
to  the  character  of  the  injury,  before  the  patient  is  subjected  to  the 
additional  risks  to  life  incident  to  an  abdominal  section. 


RECTAL   INSUFFLATION    OF  HYDROGEN   GAS.  475 

We  will  suppose  a  case.  In  a  quarrel  a  man  is  shot  in  the 
abdomen.  The  assailant  is  placed  under  arrest.  The  surgeon  who 
is  called  establishes  the  fact  that  the  bullet  has  entered  the  abdomi- 
nal cavity,  and  from  the  point  of  entrance  and  its  probable  direction, 
he  has  reason  to  believe  that  it  has  wounded  some  part  of  the  gastro- 
intestinal canal,  and  he  concludes  to  verify  his  diagnosis  by  an 
exploratory  laparotomy;  the  operation  is  performed,  and  the  most 
careful  examination  made,  but  no  visceral  wound  is  found.  The 
wound  is  closed  and  the  patient  dies  on  the  third  or  fourth  day  of 
septic  peritonitis.  The  attorney  for  the  state  charges  the  defendant 
with  murder. 

The  defense  will  very  naturally  raise  the  questions:  "Did  the 
man  die  of  the  injury,  or  the  operation?"  "Shall  the  defendant  be 
tried  for  assault  and  battery,  or  for  murder  ?"  During  the  trial  the 
attending  surgeon  is  made  the  target  for  a  volley  of  a  medley  of 
scientific  and  unscientific  questions  by  the  cunning  attorney  for  the 
defense  in  his  attempt  to  save  his  client  from  the  gallcws  or  state 
prison  for  life,  at  the  expense  of  the  reputation  of  the  surgeon  and 
the  respect  and  good  name  of  the  art  and  science  of  surgery.  This 
picture  is  not  overdrawn.  Such  cases  have  happened  and  will 
happen  again.  It  is  apparent  that  if  some  infallible  diagnostic  test 
could  be  applied  in  cases  of  penetrating  wounds  of  the  abdomen 
which  would  indicate  to  the  surgeon  the  presence  or  absence  of 
visceral  lesions  of  the  gastro-intestinal  canal,  the  indication  for 
aggressive  treatment  would  become  clear  and  the  medico-legal 
responsibility  of  the  operator  would  be  reduced  to  a  minimum. 

As  we  can  never  expect  by  a  study  of  symptoms  or  by  the  ordi- 
nary physical  examination  to  fill  this  gap,  I  was  induced  to  search 
for  some  reliable  test  which  in  such  cases  should  prove  that  the 
penetrating  bullet  or  instrument  had  injured  the  gastro-intestinal 
canal.  It  occurred  to  me  that  a  wound  in  the  stomach  or  intestine 
should  be  sought  for  in  some  such  way  as  the  plumber  locates  a 
leak  in  a  gas-pipe.  The  first  object  to  be  accomplished  was  to  prove 
the  permeability  of  the  entire  gastro-intestinal  canal  to  inflation  of 
air,  and  the  next  step  was  to  find  some  innocuous  gas  which,  when 
inflated,  would  escape  from  the  intestinal  wound  into  the  peritoneal 
cavity,  and  from  there  through  the  external  wound,  where  its  pres- 
ence could  be  proved  by  some  infallible  test. 


476  EXPERIMENTAL  SURGERY. 

I.    Permeability  of  the  Ileo-Caecal  Yalve  to  Rectal  Insuffla- 
tion of  Air  or  Gas. 

A  great  deal  has  been  said  and  written  in  reference  to  tho  per- 
meability of  the  ileo-csecal  valve  to  injections  of  fluids  into  the  rectum, 
or  to  the  insufflation  of  air  or  gases.  The  majority  of  those  who 
have  studied  this  subject  clinically  or  by  experiment  make  the  posi- 
tive assertion  that  the  ileo-ceecal  valve  is  perfectly  competent,  and 
effectually  guards  the  ileum  against  the  entrance  of  both  fluids  and 
gases  forced  into  the  rectum,  while  others  insist  that  it  is  permeable 
only  in  exceptional  cases,  and  only  a  few  claim  that  its  resistance  can 
be  overcome  by  a  moderate  degree  of  pressure.  Heschl1  made  a 
number  of  experiments  and  satisfied  himself  that  the  ileo-csecal 
valve  serves  as  a  safe  and  perfect  barrier  against  the  entrance  of 
fluids  from  below.  In  testing  the  resist.  .ig  power  of  the  coats  of 
the  intestine  he  found  that  the  serous  coat  of  the  colon  gave  way 
first  to  overdistention,  while  the  remaining  tunics  yielded  subse- 
quently to  a  somewhat  slighter  pressure.  The  small  intestine  of  a 
child  on  being  subjected  to  overdistention  ruptured  first  on  the 
mesenteric  side,  the  place  where  acquired  diverticula  are  found. 

Bull2  has  found  that  in  the  adult  one  litre  of  water  injected  by 
the  rectum  will  reach  the  caecum,  but  that  the  entire  capacity  of 
the  large  intestine  is  from  four  to  five  litres.  He  is  of  the  opinion 
that  in  the  living  body,  fluid  cannot  be  forced  beyond  the  ileo-caecal 
valve,  although  ancient  and  modern  experimenters  claim  to  have 
succeeded  in  the  cadaver.  He  affirms  that  when  the  rectum  is  dis- 
tended by  air,  the  ileo-caecal  valve  is  rendered  incompetent  and  the 
air  passes  into  the  small  intestines. 

Cantani3  is  a  firm  believer  in  the  permeability  of  the  ileo-csecal 
valve  to  fluid  rectal  injections.  In  one  instance  he  treated  a  case  of 
coprostasis  by  an  injection  of  a  litre  and  a  half  of  oil  per  rectum, 
and  an  hour  later  a  part  of  the  oil  was  ejected  by  vomiting.  He 
advises  that  the  intestinal  tract  above  the  ileo-caecal  valve  should  be 
utilized  as  an  absorbing  surface  in  cases  requiring  rectal  alimenta- 

1  Zur  Mechanik  diastaltischen  Darmperforationen.    Wiener  Med.  Wochen- 
Bchrift,  No.  1,  1881. 

2  Virchow's  Jahresbericht,  B.  11,  1878,   S.  205. 

3  Virchow's  Jahresbericht,  B.  11,  1879,  S.  180. 


PERMEABILITY   OF  ILEOCECAL    VALVE.  477 

tion,  and  that  when  in  a  diseased  condition  it  should  be  treated  by 
topical  applications. 

Behrens1  concluded  from  his  experiments  that  it  required  the 
insufflation  per  rectum  of  one  and  one-ei^htl)  litres  of  air  to  reach 
the  ileum  through  the  ileo-csecal  valve.  In  his  experiments  he  had 
no  difficulty  in  overcoming  the  competency  of  the  ileo  csecal  valve 
by  rectal  insufflation  of  air. 

Debierre"  made  numerous  experiments  on  the  cadaver  to  test 
the  permeability  of  the  ileo-csecal  valve  to  rectal  injections  of  fluids 
or  inflation  of  air.  The  results  which  he  obtained  were  not  constant. 
In  some  subjects  the  valve  proved  only  permeable  tc  air,  in  others, 
to  both  air  and  water,  while  in  some  no  air  or  fluids  could  be  forced 
into  the  ileum  by  any  degree  of  force.  When  the  intestine  was  left 
in  situ  the  valve  was  found  less  permeable  than  when  the  intestine 
had  been  removed  from  the  body.  He  attributed  the  different 
degrees  of  competency  of  the  valve  to  variations  in  the  anatomical 
construction  of  the  valve.  If  both  lips  of  the  valve  were  equal  in 
length,  or  if  the  lower  lip  was  longer  the  valve  was  found  imper- 
meable. It  proved  permeable  in  cases  where  the  lower  lip  was 
shorter,  contracted,  and  smaller  than  the  upper.  In  the  last  instance, 
the  advancing  volume  of  fluid  or  air  lifted  the  upper  valve,  while 
in  the  former  structure  of  the  valve,  the  margins  of  the  lips  of  the 
valve  were  pressed  against  each  other,  perfectly  shutting  off  all  com- 
munication between  the  colon  and  the  ileum. 

Mr.  Lucas3  enumerates  the  following  objections  against  forcible 
rectal  injections  of  water  as  a  means  of  reducing  invagination: 

1.  Owing  to  its  weight  it  exerts  much  too  strong  lateral 
pressure  for  the  intestine  safely  to  bear,  and  he  has  found  it  easy  to 
rupture  the  bowel  after  death  by  forcing  in  water. 

2.  Should  reduction  have  been  accomplished,  the  contact  of 
a  large  quantity  of  water  with  the  large  bowel  is  apt  to  increase 
the  tendency  to  diarrhoea.  He  claims  very  properly,  that  air,  on  the 
other  hand,  is  a  natural  occupant  of  the  intestinal  canal,  and  whilst 

1  Ueber   den  Werth  der    Kunstlichen    Auftreibung    des    Dickdarmes   mit 
Gasen  u.  Flussigkeiten.     Gottingen.     Dissertation.     1886. 

2  La  valvule  de  Bauhin  considered  comine  barriere  des  apothicaires.    Lyon 
M6dicale,  No.  45,  1885. 

!()n  Inversion  with  Inflation  in  the  Cure  of  Intussusception.    The  Lan- 
cet, January  16,  1886. 


478  EXPERIMENTAL  SURGERY. 

its  pressure  is  of  the  gentlest  its  presence  excites  no  unnatural 
peristaltic  action.  He  administers  an  anaesthetic  to  the  point  of 
relaxation  before  the  inflation  is  attempted. 

Dawson'  made  a  number  of  experiments  on  the  cadaver  and 
came  to  the  conclusion  that  when  the  ileo-csecal  valve  is  in  a  normal 
condition  it  effectually  guards  the  small  intestine  against  the  ingress 
of  fluids  from  below.  Illoway2  has  devised  a  force-pump  which  he 
strongly  recommends  for  the  purpose  of  forcing  water  beyond  the 
ileo-csecal  valve,  in  case  the  seat  of  an  intestinal  obstiuction  is  located 
above  that  point.  He  reports  four  cases  of  intestinal  obstruction 
treated  by  this  method,  three  of  which  recovered.  Battey3  asserts  the 
permeability  of  the  entire  alimentary  canal  by  enema,  and  verifies 
his  statement  by  the  recital  of  his  own  clinical  experience  and 
experiments  upon  the  cadaver. 

Ziemssen  recommends  inflation  of  the  rectum  for  diagnostic 
and  therapeutic  purposes  and  proceeds  as  follows :  A  rectal  tube 
about  six  inches  long  is  carried  into  the  anus  and  fixed  by  pressing 
together  the  nates,  the  patient  lying  on  the  back.  A  funnel  is  then 
connected  with  the  rectal  tube  by  means  of  rubber  tubing.  For 
complete  inflation  of  the  large  intestine  three  drams  of  bicarbonate 
of  soda  and  four  and  a  half  drams  of  tartaric  acid  are  separately  dis- 
solved in  water  and  portions  of  either  solution  alternately  added. 
To  prevent  sudden  overdistention  of  the  bowel  it  is  advised  to  add 
the  solutions  at  intervals  of  several  minutes.  A  very  important  use 
of  this  method  is  to  diagnosticate  the  position  of  contractions,  stric- 
tures, or  occlusion  of  the  intestine  in  cases  in  which  it  is  desirable 
to  operate,  and  also  to  show  the  position  of  peritoneal  adhesions. 
The  result  of  his  observations  has  led  him  to  believe  that,  as  a  rule, 
the  small  intestine  is  completely  closed  to  the  entrance  of  substances 
from  the  colon,  by  the  ileo-csecal  valve.  Under  the  influence  of 
deep  chloroform  narcosis,  however,  this  resistance  is  lessened,  and 
fluids  can  be  thrown  into  the  small  intestine. 

Since  this  work  has  gone  to  press  my  attention  has  been  called 
by  Dr.  Eastman,  of  Indianapolis,  to  a  paper  on  "  Fifty  Laparotomies," 
etc.,  which  he  published  in  Progress,  for  January,  1888,  in  which 

1  Lancet  and  Clinic,  Feb.  21,  1885. 

2  American  Journal  Medical  Sciences,  Vol.  41,  p.  168. 

3  Transactions  of  the  American  Medical  Association,  1878. 


PERMEABILITY   OF  ILEO-CECAL    VALVE.  479 

he  describes  a  case  of  pelvic  abscess  where  he  resorted  to  Bergeon's 
method  of  rectal  insufflation  of  sulphuretted  hydrogen  gas  after 
the  abscess  was  opened,  to  determine  whether  it  communicated  with 
the  large  intestine.  In  the  same  paper  appears  a  case  of  resection 
of  the  colon  where  the  same  test  was  used  after  suturing,  to  prove 
the  efficiency  of  the  sutures. 

In  my  paper  read  at  the  last  International  Medical  Congress1 
the  following  experiments  appear,  which  illustrate  the  difficulty  in 
overcoming  the  resistance  of  the  ileo-c?ecal  valve  by  rectal  injections 
of  water: 

Experiment  23.  While  completely  under  the  influence  of  ether,  an  incision 
was  made  through  the  linea  alba  of  a  cat,  sufficiently  long  to  render  the  ileo- 
cecal region  readily  accessible  to  light.  An  incision  was  made  into  the  ileum 
just  above  the  valve  and  by  gently  retracting  the  margins  of  the  wound,  the 
valve  could  be  distinctly  seen.  Water  was  then  injected  into  the  rectum,  and 
as  the  caecum  became  well  distended  it  could  be  readily  seen  that  the  valve 
became  tense  and  appeared  like  a  circular  curtain,  preventing  effectually  the 
escape  even  of  a  drop  of  fluid  into  the  ileum.  The  competency  of  the  valve 
was  only  overcome  by  overdistention  of  the  caecum,  which  mechanically  sepa- 
rated its  margins,  allowing  a  fine  stream  of  water  to  escape  into  the  ileum. 
The  insufficiency  of  the  valve  was  clearly  caused  by  great  distention  of  the 
cecum.  That  such  a  degree  of  distention  is  attended  by  no  inconsiderable 
danger,  was  proved  by  this  experiment,  as  the  cat  was  immediately  killed,  and 
on  examination  of  the  colon  and  rectum,  a  number  of  longitudinal  rents  of 
the  peritoneal  coat  was  found. 

Experiment  24.  In  this  experiment  a  cat  was  fully  narcotized  with  ether 
and  while  the  body  was  inverted,  water  was  injected  per  rectum  in  sufficient 
quantity  and  adequate  force,  by  means  of  an  elastic  syringe,  to  ascertain  the 
force  required  to  overcome  the  resistance  offered  by  the  ileo-caecal  valve. 
Great  distention  of  the  caecum  could  be  clearly  mapped  out  by  percussion  and 
palpation  before  any  fluid  passed  into  the  ileum.  As  soon  as  the  obstruction 
at  the  valve  was  overcome,  the  water  rushed  through  the  small  intestines,  and 
having  traversed  the  entire  alimentary  canal,  issued  from  the  mouth.  About 
a  quart  of  water  was  forced  through  in  this  manner.  The  animal  was  killed 
and  the  gastro-intestinal  canal  carefully  examined  for  injuries.  Two  longi- 
tudinal lacerations  of  the  peritoneal  surface  of  the  rectum,  over  an  inch  in 
length,  were  found  on  opposite  sides  of  the  bowel. 

Experiment  25.  This  experiment  was  conducted  in  the  same  manner  as 
the  foregoing,  only  that  the  cat  was  not  etherized.  More  than  a  quart  of 
water  was  forced  through  the  entire  alimentary  canal  from  anus  to  mouth. 
The  animal  lived  for  eight  days,  but  suffered  during  the  whole  time  with 


1  An    Experimental    Contribution    to    Intestinal    Surgery    with    Special 
Reference  to  the  Treatment  of  Intestinal  Obstruction. 


•180  EXPERIMENTAL  SURGERY. 

symptoms  of  ileo-colitis.  A  post-mortem  examination  was  not  made,  although 
the  symptoms  manifested  during  life  leave  no  doubt  that  they  resulted  from 
injuries  inflicted  by  the  injection. 

It  will  thus  be  seen  that  in  the  three  cases  where  fluid  was 
forced  beyond  the  ileo-csecal  valve,  in  two  of  them  the  post-mortem 
revealed  multiple  lacerations  of  the  peritoneal  coat  of  the  large 
intestines,  while  the  third  animal  sickened  immediately  after  the 
experiment  was  made,  and  died  eight  days  later  from  the  effects 
of  the  injuries  inflicted.  These  experiments  combined  with  clinical 
experience  leave  no  further  doubt  that,  practically,  the  ileo-csecal 
valve  is  not  permeable  to  fluids  from  below,  and  that  for  diagnostic 
and  therapeutic  uses  it  is  unsafe  and  unjustifiable  to  attempt  to 
force  fluids  beyond  the  ileo-csecal  valve.  We  should  a  priori  expect 
that  air  and  gases,  on  account  of  their  less  weight  and  greater 
elasticity  than  water,  could  be  forced  along  the  intestinal  canal  with 
less  force,  and  for  that  reason  alone,  if  for  no  other,  should  be  pre- 
ferred to  water  in  cases  where  it  appears  desirable  to  distend  the 
intestine  above  the  ileo-ceecal  valve.  The  results  obtained  by  experi- 
mental research  in  the  past  speak  in  favor  of  rectal  inflation  by  air 
or  gas  in  all  cases  where  for  diagnostic  or  therapeutic  purposes  it 
becomes  necessary  to  dilate  the  entire  or  a  portion  of  the  gastro- 
intestinal canal. 

i.     Rectal  Insufflation  of  Air. 

Experiment  I.1  Dog,  weight  seventy-five  pounds.  The  animal  was  pro- 
foundly anesthetized,  and  by  means  of  an  ordinary  elastic  syringe,  air  was 
forced  through  the  rectum  until  the  whole  abdomen  became  distended  and 
tympanitic.  The  abdominal  cavity  was  opened  in  the  median  line,  and  the 
whole  intestinal  canal  was  found  distended.  An  incision  about  an  inch  in 
length  was  made  about  the  middle  of  the.  small  intestines,  when  air  escaped, 
and  about  one  foot  of  the  intestine  on  either  side  of  the  wound  collapsed. 
The  remaining  portion  of  the  intestines  remained  unaffected  by  the  incision. 
The  animal  was  killed,  and  every  part  of  the  entire  gastro-intestinal  canal 
carefully  examined  for  injuries.  The  ileo-caecal  valve"  remained  intact,  and 
no  evidence  of  rupture  of  any  of  the  coats  of  the  intestines  could  be  detected. 

Experiment  2.  Dog,  weight  twelve  pounds.  Under  full  anesthesia  the 
gastro-intestinal  canal  was  inflated  in  the  same  manner  as  in  the  preceding 
experiment,  and  the  inflation  was  carried  to  the  same  extent.    On  opening  the 


1  These  experiments  were  made  at  the  County  Hospital,  and  my  thanks 
are  due  to  Dr.  M.  E.  Connel,  superintendent  of  the  hospital,  and  his  assistants, 
and  Dr.  Wm.  Mackie  of  Milwaukee,  for  valuable  assistance. 


RECTAL   INSUFFLATION    OF  AIR.  481 

abdomen  in  the  median  line  the  distended  loops  of  the  intestines  protruded 
from  the  wound,  and  partial  exventration  was  allowed  to  take  place  for  the 
purpose  of  examining  the  intestine  for  injuries.  The  closest  inspection  failed 
to  detect  evidences  of  partial  or  complete  rupture  of  any  of  the  tunics.  One 
of  the  distended  coils  of  intestine  was  incised  at  opposite  points  on  the  lateral 
aspect,  the  incisions  being  an  inch  in  length.  Only  a  limited  segment  of  the 
bowel  on  each  side  of  the  wounds  collapsed,  and  although  the  peristalsis  was 
active,  more  remote  portions  were  emptied  very  slowly.  The  wounds  were 
united  transversely  for  the  purpose  of  making  an  artificial  diverticulum.  The 
animal  recovered  without  any  untoward  symptoms. 

Experiment  3.  Dog,  weight  thirteen  pounds.  Animal  profoundly  etherized, 
and  air  inflated  as  in  former  experiments.  The  distended  colon  could  be 
clearly  mapped  out  by  percussion  before  a  gurgling  sound  in  the  region  of  the 
ileo-caecal  valve  indicated  that  the  air  had  entered  the  ileum.  After  this  had 
occurred  the  middle  of  the  abdomen  became  prominent  and  tympanitic.  As 
soon  as  the  resistance  offered  by  the  ileo-ca?cal  valve  had  been  overcome, 
it  required  less  force  to  distend  the  remaining  portion  of  the  gastro-intestinal 
canal.  The  inflation  was  carried  to  the  extent  of  distending  the  stomach,  an 
event  which  was  easily  recognized  by  a  considerable  prominence  in  the 
epigastric  region  which  was  tympanitic  on  percussion.  At  this  time  an 
elastic  tube  was  inserted  into  the  stomach,  and  its  free  end  immersed  under 
water.  Babbles  of  air  escaped  freely,  and  the  abdominal  distention  was 
materially  diminished.  As  the  inflation  was  continued  the  air  would  escape 
through  the  stomach-tube,  showing  that  a  moving  current  of  air  existed 
between  the  rectal  tube  and  the  stomach  tube.  The  abdominal  distention 
which  remained  after  the  experiment  had  completely  disappeared  after 
eighteen  hours,  and  the  animal  never  manifested  pain  or  any  other  symptoms 
of  disease. 

Experiment  4.  Dog,  weight  fifteen  pounds.  In  this  experiment  inflation 
was  practiced  without  anaesthesia.  The  rigidity  of  the  abdominal  muscles 
greatly  interfered  with  the  distention  of  the  colon  to  a  requisite  degree 
to  overcome  the  competency  of  the  ileo-cacal  valve.  The  passage  of  air  from 
the  caecum  into  the  ileum  through  the  ileo-ctecal  valve  was  announced  by  an 
audible  gurgling  sound  which  was  repeated  at  intervals,  as  the  caecum,  after 
partial  collapse,  was  again  distended  by  renewing  the  inflation.  The  insuffla- 
tion was  continued  until  the  stomach  became  distended  by  air,  which  caused 
vomiting  and  copious  eructations  of  air.  The  dog  remained  in  perfect  health 
after  the  inflation. 

These  experiments  prove  the  feasibility  of  forcing  air  through 
the  entire  alimentary  canal  from  below  upwards.  In  not  a  single 
experiment  could  any  structural  changes  bo  found  in  the  walls  of  the 
intestine,  and  all  animals  not  killed  immediately  after  the  experiment 
recovered.  The  results  of  these  experiments  contrast  strongly  with 
those  by  rectal  injections  with  water  whore  tho  saino  objects  were  in 


482  EXPERIMENTAL  SURGERY. 

view.  In  the  latter  experiments  the  force  requisite  to  overcome  the 
ileo-caecal  valve  invariably  produced  lacerations  of  the  peritoneal 
coat  of  the  bowel,  which  in  themselves  would  constitute  a  grave 
source  of  danger. 

It  now  became  necessary  for  me  to  prove  that  the  ileo-csecal 
region  in  man  in  so  far  resembled  that  of  the  dog,  that  the  ileo- 
cecal valve  could  be  rendered  more  readily  incompetent  by  inflation 
of  air  than  by  injections  of  fluids.  The  following  two  experiments 
were  made  for  this  purpose: 

Experiment  5.  A  young  man,  twenty-five  years  of  age,  a  patient  in  the 
Milwaukee  Hospital,  under  treatment  for  a  tumor  in  the  epigastric  region,  was 
subjected  to  the  experiment.  He  was  placed  flat  on  the  back.  On  percussion 
the  whole  umbilical  region  was  found  flat  and  the  abdominal  wall  retracted. 
No  antesthesia.  With  an  ordinary  elastic  syringe  air  was  injected  slowly  into 
the  rectum.  As  inflation  progressed  the  outlines  of  the  entire  colon  could  be 
clearly  seen  and  accurately  mapped  out  by  percussion.  The  csecal  region 
especially  became  very  prominent.  The  inflation  was  continued  very  slowly, 
and  as  soon  as  the  air  passed  through  the  ileo-csecal  valve,  the  hypogastric  and 
umbilical  regions  began  to  rise  and  resonance  replaced  the  former  dullness  on 
percussion.  The  arrival  of  air  in  the  stomach  was  indicated  by  distention  of 
the  epigastric  region,  disappearance  of  the  contour  of  the  tumor  and  resonance 
on  percussion.  During  the  whole  process  of  inflation  the  patient  only  com- 
plained of  a  slight  pain  in  the  splenic  flexure  of  the  colon,  and  a  sensation  of 
fullness  in  the  abdomen.  As  soon  as  it  became  apparent  that  the  stomach 
was  distended  by  air,' a  stomach-tube  was  introduced  and  its  free  end  placed 
under  water.  As  the  inflation  was  continued,  bubbles  of  air  continued  to  escape. 
On  assuming  the  erect  position  the  patient  complained  of  colicky  pains  in  the 
umbilical  region,  which  were  undoubtedly  caused  by  an  exaggerated  peristalsis. 
The  pain,  however,  soon  disappeared,  and  on  the  following  day  he  was  as  well 
as  usual. 

Experiment  6.  Adult  male,  suffering  from  neurasthenia.  Experiment  and 
result  the  same  as  in  No.  5,  only  that  in  this  case  the  pain  due  to  distention  of 
the  colon  was  referred  to  the  ileo-caecal  region,  and  the  colicky  pain  in  the 
umbilical  region  persisted  for  a  longer  time.  The  air  was  again  forced  from 
anus  to  mouth  without  causing  any  injury  whatever  and  only  moderate  degree 
of  pain  for  a  short  time. 

The  foregoing  experiments  demonstrate  conclusively  that  in  the 
human  subject  by  a  moderate  degree  of  force,  short  of  producing 
any  injury  of  the  tunics  of  the  intestines,  air  can  be  forced  along  the 
entire  alimentary  tract,  and  that  this  procedure  can  be  resorted  to 
with  perfect  safety  for  diagnostic  and  therapeutic  purposes  in  all 
cases  where  the  tissues  of  the  intestinal  wall  have  not  suffered  too 
much  loss  of  resistance  from  antecedent  pathological  changes. 


INFLATION   OF  GAS   THROUGH  STOMACH.  483 

2.   Inflation  of  Alimentary  Canal  through  Stomach  Tube. 

We  should  naturally  expect  that  the  alimentary  canal  could  be 
inflated  with  more  ease  and  with  a  less  degree  of  force  by  following 
the  normal  peristaltic  wave.  That  this  is  not  the  case  will  be  seen 
from  the  following  experiments: 

Experiment  7.  Dog,  weight  forty  pounds  (18  kilograms).  After  com- 
plete anaesthesia  was  effected  a  flexible  rubber  tube  was  introduced  into  the 
6tomach,  and  the  free  end  of  the  tube  connected  with  a  four-gallon  rubber 
Walloon  containing  hydrogen  gas,  by  means  of  a  rubber  tube.  Between  the 
gas  reservoir  and  the  stomach-tube  a  manometer  was  interposed,  registering 
accurately  the  force  used  in  making  the  inflation.  The  inflation  was  made  by 
compressing  the  rubber  bag.  A  tube  was  introduced  into  the  rectum  to  facili- 
tate the  escape  of  gas  that  might  reach  this  portion  of  the  intestinal  tract. 
Under  a  pressure  of  one  pound  and  a  half  the  stomach  dilated  rapidly,  and 
later  the  entire  abdomen  became  distended  and  resonant  on  percussion,  but 
no  gas  escaped  per  rectum.  When  the  pressure  was  increased  to  two  pounds 
(.9  kilogram),  no  further  distention  of  the  abdomen  took  place,  as  the  gas 
escaped  along  the  side  of  the  stomach  tube.  At  this  time  respiration  became 
greatly  embarrassed,  but  was  relieved  on  allowing  gas  to  escape  through  the 
stomach-tube.  On  compressing  the  abdomen  firmly  the  distention  disappeared 
almost  completely;  at  the  same  time  a  large  quantity  of  gas  continued  to 
escape  through  the  stomach-tube.  Inflation  was  renewed,  and  under  a  pressure 
of  one  pound  and  a  half,  the  abdomen  again  became  uniformly  distended. 
When  the  pressure  was  increased  to  two  pounds  (.9  kilogram)  the  dog  sud- 
denly died,  and  all  efforts  at  resuscitation  failed.  On  opening  the  abdomen 
the  stomach  was  found  enormously  distended,  reaching  three  inches  below  the 
umbilicus,  occupying  almost  the  entire  abdominal  cavity.  The  upper  half  of 
the  small  intestines  was  distended;  numerous  points  of  sharp  flexions  were 
found  among  the  different  distended  coils.  The  distended  stomach  had 
evidently  encroached  so  much  upon  the  abdominal  space  as  to  render  the 
greater  part  of  the  intestinal  canal  impermeable  by  pressure. 

h'.ijjrriiiu'iit  ■-.  Dog,  weight  fifteen  pounds.  After  the  animal  was  placed 
fully  under  the  influence  of  ether,  the  abdomen  was  opened  and  the  cascurn 
and  lower  portion  of  ileum  drawn  forward  into  the  wound,  and  a  large  aspi- 
rator needle  inserted  into  the  ileum  just  above  the  ileo-caecal  valve.  Through 
a  rubber  tube  hydrogen  gas  was  forced  into  the  stomach.  Under  one  pound 
i.f.")  kilogram)  of  pressure,  the  stomach  and  upper  portion  of  the  intestines 
dilated  readily.  When  the  force  was  increased,  the  gas  returned  through  the 
oesophagus  along  the  sides  of  the  stomach-tube. 

Experiment  9.  Dog,  medium  size.  This  animal  was  killed  to  ascertain 
the  results  of  an  experiment  made  for  another  purpose.  Rubber  balloon  con- 
taining hydrogen  ^as,  and  manometer  were  used  for  making  the  inflation. 
The  tube  through  which  the  inflation  was  made  was  tied  in  the  oesophagus. 
The  abdomen  was  distended  enormously,  and  on  increasing  the  pressure  to 


484  EXPERIMENTAL   SURGERY. 

three  and  three-fourths  pounds  (1.7  kilograms),  still  no  gas  escaped  through 
the  rectal  tube.  The  abdomen  was  then  opened,  when  the  stomach  was  found 
so  enormously  distended  that  it  filled  almost  the  entire  abdominal  cavity. 
About  one-fourth  of  the  length  of  the  small  intestines  was  found  distended, 
and  among  the  distended  loops  numerous  acute  flexions  could  be  seen.  After 
the  abdomen  was  opened,  under  long  and  continuous  distention,  the  peritoneal 
covering  of  the  stomach  gave  way,  when  the  manometer  registered  only  one 
pound  and  a  half  of  pressure. 

Experiment  10.  Dog,  weight  eighteen  pounds  (8  kilograms).  Immedi- 
ately after  death  the  oesophagus  was  isolated  and  the  tube  of  the  hydrogen 
gas  inflator  securely  tied  in,  and  a  glass  tube  was  inserted  into  the  rectum. 
Under  a  pressure  of  two  and  three-fourths  pounds  (1.2  kilograms),  registered 
by  the  manometer,  the  gas  first  dilated  the  Stomach  and  then  passed  along  the 
intestines  until  it  escaped  in  a  steady  stream  through  the  rectal  tube,  where  it 
was  ignited.  On  opening  the  abdomen  the  stomach  was  found  greatly  dis- 
tended, while  the  distention  of  the  intestines  was  a  great  deal  less  marked. 
None  of  the  tunics  of  the  stomach  or  intestines  were  injured. 

Experiment  11.  Dog,  weight  twenty  pounds  (9  kilograms).  Animal 
etherized  and  a  flexible  tube  connected  with  the  gas  inflator  introduced  into 
the  stomach,  and  a  glass  tube  into  the  rectum.  On  inflation  the  stomach 
became  gradually  distended,  and  when  the  pressure  had  reached  one  pound 
and  a  half  (.7  kilogram),  the  dog  vomited  and  a  good  deal  of  gas  escaped  at 
the  same  time.  Inflation  was  again  commenced  and  was  followed  by  uniform 
distention  and  tympanites  over  the  entire  abdomen;  when  the  pressure 
reached  two  pounds  and  a  half  (1.1  kilograms),  the  gas  escaped  from  the 
rectum,  and  when  ignited  burned  with  a  steady  blue  flame.  The  experiment 
was  followed  by  no  unfavorable  symptoms. 

Experiment  12.  Dog,  weight  twelve  pounds  (5.4  kilograms).  Under  the 
influence  of  ether  inflation  with  hydrogen  gas  in  the  same  manner  as  in  last 
experiment.  As  soon  as  the  stomach  became  well  distended,  and  the  manom- 
eter registered  one  pound  and  a  half  of  pressure,  vomiting  occurred,  attended 
by  a  free  escape  of  gas,  which  was  followed  by  collapse  of  the  distended 
epigastric  region.  When  inflation  was  resumed,  it  was  noted  that  any  increase 
of  pressure  over  one  pound  (.45  kilogram)  was  followed  by  regurgitation  of 
gas,  and  on  this  account  it  was  found  impossible  to  inflate  the  lower  portion 
of  the  intestinal  tract.     No  unfavorable  symptoms  followed  the  experiment. 

Experiment  13.  Dog,  weight  twenty-eight  pounds  (12.7  kilograms).  Under 
the  influence  of  ether  inflation  of  hydrogen  gas  through  the  stomach  tube. 
As  soon  as  the  pressure  was  increased  to  more  than  one  pound  (.45  kilo- 
gram) the  gas  escaped  along  the  sides  of  the  tube  through  the  oesophagus; 
consequently  only  the  upper  portion  of  the  abdomen  could  be  distended,  and 
the  inflation  evidently  did  not  extend  much  beyond  the  stomach.  The  experi- 
ment was  repeated  several  times  with  the  same  result.  The  animal  remained 
perfectly  well  after  the  experiment. 

Experiment  14.  Dog,  weight  twelve  pounds  (5.4  kilograms).  Inflation  of 
stomach  by  hydrogen  gas  under  full  anaesthesia.      The  effect  of    the  infla- 


PRESSURE   EXPERIMENTS.  485 

tion  was  the  same  as  in  the  last  experiment;  only  the  stomach  and  upper 
portion  of  the  small  intestines  could  be  distended  and  further  inflation  was 
impossible,  as  the  gas  escaped  from  the  stomach  as  soon  as  the  pressure 
exceeded  one  pound  (.45  kilogram).  A  large  aspirator  needle  was  pushed 
through  the  linea  alba  into  the  stomach,  and  the  gas  which  escaped  through  it, 
on  being  lighted,  burned  with  the  characteristic  blue  flame.  After  the  needle 
was  withdrawn,  the  inflation  was  continued  to  ascertain  if  the  puncture  in  the 
stomach  would  allow  the  escape  of  gas  into  the  peritoneal  cavity.  The  infla- 
tion was  continued  until  the  entire  abdomen  was  distended  by  the  gas.  That 
the  distention  and  tympanites  was  due  to  the  presence  of  gas  in  the  peritoneal 
cavity  became  evident,  as  it  remained  after  the  stomach  had  been  emptied  of 
its  gas,  and  on  percussion  it  was  ascertained  that  the  entire  liver  dullness  had 
disappeared.  The  dog  recovered  without  symptoms  of  peritonitis  or  any 
other  ill-effects  from  the  experiment. 

These  experiments  demonstrate  conclusively  that  it  is  more 
difficult  to  inflate  the  alimentary  canal  from  above  downwards  than 
from  below  upwards,  as  in  the  living  animal  I  succeeded  only  in  one 
instance  in  forcing  hydrogen  gas  from  mouth  to  anus,  while  in  others 
a  degree  of  force  sufficient  to  rupture  the  peritoneal  coat  of  the 
stomach,  only  effected  distention  of  the  stomach  and  upper  portion 
of  intestinal  canal.  It  is  evident  that  great  distention  of  the 
stomach  constitutes  an  important  factor  in  causing  or  aggravating 
intestinal  obstruction,  as  it  effects  compression  which  causes 
impermeability  of  the  intestines,  or  aggravates  conditions  arising 
from  an  antecedent  partial  permeability,  by  producing  sharp  flexions 
among  the  distended  coils  of  the  intestines.  For  diagnostic  and 
surgical  purposes  the  stomach  can  be  readily  inflated  almost  to  any 
extent  through  a  stomach  tube,  and  when  it  becomes  necessary  to 
ascertain  the  presence  of  a  visceral  wound  or  perforation  of  this 
organ,  this  method  of  inflation  may  be  resorted  to  with  advantage. 

3.     Experiments  to  Determine  the  Degree  of  Force  which 

is  Necessary  to  Overcome  the  Resistance  Offered 

by  the  Ileo-Caecal  Valve. 

Accurate  experiments  to  determine  the  force  required  to  render 
th»"  ileo-csecal  valve  incompetent  by  insufflation  of  air  or  gas  having 
not  heretofore  1» 'I'll  made,  as  it  is  exceedingly  important  to  obtain 
some  accurate  information  on  this  subject,  the  following  experiments 
were  made.  In  all  experiments  air  or  hydrogen  gas  was  used.  The 
inflation  was  made  with  a  rubber  balloon.      The  pressure  was  esti- 


486  EXPERIMENTAL  SURGERY. 

mated  either  with  a  mercury  gauge  or  with  a  manometer,  as  used  by 
gas-fitters  and  plumbers.  The  manometer  or  mercury  gauge  was 
connected  by  means  of  rubber  tubing  with  the  rectal  tube  on  one 
side  and  the  rubber  balloon  on  the  other.  The  rubber  balloon  in 
which  the  hydrogen  gas  was  collected  held  four  gallons,  and  numer- 
ous experiments  showed  that  when  the  gas  was  forced  through  the 
opening  of  a  stopcock,  the  lumen  of  which  was  about  the  size  of  a 
knitting  needle,  a  compression  equal  to  two  hundred  pounds  (91 
kilograms)  would  never  register  more  than  three  pounds  (1.4  kilo- 
grams) of  pressure.  In  the  living  subject  the  escape  of  air  or  gas 
from  the  rectum  was  prevented  by  an  assistant  pressing  the  margins 
Of  the  anus  firmly  against  the  rectal  tube. 

Experiment  15.  Dog,  'weight  thirty-five  pounds  (16  kilograms).  Imme- 
diately after  death  the  lower  portion  of  the  rectum  was  isolated  and  the 
rectal  tube  inserted  and  fixed  in  its  place  by  tying  a  string  firmly  around 
the  rectum.  The  abdomen  was  opened  and  the  intestines  left  in  situ.  The 
ileum  was  cut  transversely  six  inches  above  the  ileo-csecal  valve  and  a  glass 
tube  inserted  into  the  distal  end,  which  was  also  tied  in.  Hydrogen  gas  was 
inflated  from  a  rubber  balloon.  Under  a  pressure  of  three-quarters  of  a 
pound  (.3  kilogram)  the  caecum  was  dilated,  and  a  moment  later  the  gas 
escaped  from  the  glass  tube  and  was  ignited;  the  flame  remained  steady 
under  a  pressure  of  from  one-half  to  three-quarters  of  a  pound  (.2  to  .3 
kilogram). 

Experiment  16.  Dog,  weight  twenty  pounds  (9  kilograms).  Same  as  in 
the  preceding  experiment,  only  that  the  resistance  of  the  ileo-csecal  valve  was 
overcome  under  a  pressure  of  one-half  pound  (.2  kilogram).  The  distention 
of  colon  and  caecum  was  moderate,  and  signs  of  injury  to  the  tunics  could  not 
be  found  in  either  experiment. 

Experiment  17.  Dog,  weight  twenty-three  pounds  (10  kilograms).  In 
this  experiment  the  abdomen  was  opened  immediately  after  death,  and  a  large 
hypodermic  needle  inserted  into  the  ileum  a  short  distance  above  the  ileo- 
caecal  valve  before  the  inflation  of  hydrogen  gas  was  made.  A  pressure  of 
three-quarters  of  a  pound  (.3  kilogram)  was  sufficient  to  force  the  gas  through 
the  ileo-caecal  valve  and  through  the  needle;  the  valve  remained  open  under  a 
steady  pressure  of  one-half  pound  (.2  kilogram). 

Having  determined  that  air  and  gas  could  be  forced  beyond  the 
ileo-csecal  valve  in  dogs  under  very  low  pressure,  varying  from  one- 
half  to  three-quarters  of  a  pound,  I  proceeded  to  test  the  degree  of 
resistance  of  the  ileo-ctecal  valve  in  the  human  subject. 

Experiment  18.  Strong,  healthy  young  man.  The  subject  was  placed  flat 
upon  his  back  and  hydrogen  gas  was  inflated  from  a  rubber  balloon.  At  first 
the  gas  was  forced  in  very  slowly  under  a  pressure  of  one  pound  and  a  half 


PRESSURE  EXPERIMENTS.  487 

(.7  kilogram),  which  distended  the  colon  visibly  as  far  as  the  cajcum.  As 
the  distention  appeared  to  remain  the  same,  the  pressure  was  increased  to  two 
pounds  (.9  kilogram),  when  suddenly  the  indicator  of  the  manometer  receded 
to  one  pound  (.45  kilogram),  and  the  umbilical  region  became  prominent 
and  resonant,  showing  conclusively  that  the  ileo-esecal  valve  had  been  passed 
and  the  small  intestines  were  filling  rapidly  with  gas.  As  soon  as  the  whole 
abdomen  had  become  distended  and  tympanitic,  the  manometer  again  regis- 
tered one  pound  and  a  half  (.7  kilogram)  of  pressure,  and  remained  at  this 
figure  for  some  time  after  further  inflation  was  discontinued  by  turning  the 
stopcock. 

Experiment  19.  Young  man,  in  good  health.  Experiment  conducted  in 
the  same  manner  as  before.  After  the  colon  and  cascum  had  been  well  dilated 
the  manometer  registered  two  and  one-quarter  pounds  (1  kilogram),  and  the 
umbilical  region  became  prominent  and  resonant.  As  the  inflation  advanced 
the  average  pressure  was  one  pound  and  three-quarters  (.8  kilogram),  and 
twice  it  was  increased  to  two  and  a  half  pounds  (1.1  kilograms),  when  the 
patient  complained  of  pain  in  the  umbilical  region.  As  soon  as  the  stopcock 
was  turned  the  pressure  sank  to  three-quarters  of  a  pound  (.3  kilogram). 

These  two  experiments  prove  that  in  a  normal  condition  the 
ileo-csecal  valve  in  a  healthy  adult  person  is  overcome  by  rectal 
inflation  under  a  pressure  of  one  and  a  half  to  two  and  a  quarter 
pounds  (.7  to  1.1  kilograms).  This  amount  of  pressure  is  not 
sufficient  to  injure  the  tunics  of  a  healthy  intestine,  and  in  both 
instances  the  subjects  of  the  experiments  complained  but  little  of 
the  immediate  or  remote  effects  of  the  experiments.  As  the  result 
of  numerous  observations,  I  can  state  that  when  the  inflation  is  made 
slowly  and  continuously  there  is  less  danger  of  injuring  the  intes- 
tines than  when  the  inflation  is  made  rapidly,  or  with  interruptions. 
Slow  and  gradual  distention  of  the  caecum  is  best  adapted  to 
overcome  the  competency  of  the  ileo-csecal  valve,  by  effecting  dias- 
tasis of  the  margins  of  the  valve.  A  rubber  balloon  holding  from 
two  to  four  gallons  (10  to  20  litres)  recommends  itself  as  the  most 
efficient  and  safest  instrument  for  making  rectal  insufflation  for 
therapeutic  or  diagnostic  purposes. 

The  following  experiments  were  made  t<>  determine: 

4.    The  Amount  of  Pressure  Necessary  to  Force  Hydrogen 

Gas  Through  the  Entire  Alimentary  Canal 

by  Rectal  Inflation. 

Experiment,  20.  Dog,  weight  thirty-five  pounds  (1(3  kilograms).  Immedi- 
ately after  death  rectal  inflation  <>f  hydrogen  gas  was  made,  and  a  pressure  of 
one  pound  (.46  kilogram)  sufficed  to  distend  the  entire  abdominal  cavity,  and 


488  EXPERIMENTAL   SURGERY. 

when  a  tube  was  introduced  into  the  stomach  and  a  burning  taper  applied  to 
its  end,  a  blue  flame  at  once  appeared  and  continued  as  long  as  the  inflation 
was  kept  up  under  the  same  pressure. 

Experiment  21.  Dog,  weight  twelve  pounds  (5.4  kilograms).  Under  ether 
narcosis  rectal  inflation  of  hydrogen  gas  from  rubber  balloon.  The  ileo-caecal 
valve  offered  very  little  resistance,  and  as  soon  as  the  manometer  registered 
one  pound  and  a  half  (.7  kilogram)  of  pressure  the  gas  escaped  through  the 
stomach  tube  which  had  been  introduced  previously,  and  on  applying  a  lighted 
taper  it  burned  with  a  continuous  flame  as  long  as  the  inflation  was  continued. 

Experiment  22.  Dog,  weight  twenty  pounds  (9  kilograms).  Experiment 
and  result  same  as  in  last;  the  pressure  never  exceeded  one  pound  and  a  half 
(.7  kilogram). 

Experiment  23.  Dog,  weight  nineteen  pounds  (8.6  kilograms).  In  this 
experiment  no  anaesthetic  was  used,  and  in  consequence  the  pressure  had  to  be 
increased  to  three  pounds  (1.4  kilograms)  before  the  gas  escaped  through  the 
stomach  tube.  On  account  of  the  violent  contractions  of  the  abdominal  muscles 
the  escape  of  gas  was  intermittent,  the  flame  being  frequently  extinguished 
by  an  absence  of  the  gas. 

Experiment  24.  Dog,  weight  twenty-one  pounds  (9.5  kilograms).  The 
animal  being  completely  under  the  influence  of  ether  the  abdomen  was  opened 
in  the  median  line,  and  the  ileo-caecal  region  made  accessible  to  sight.  Hydro- 
gen gas  was  inflated  per  rectum,  and  under  a  pressure  of  three-quarters  of  a 
pound  (.3  kilogram)  readily  passed  the  ileo-caecal  valve,  and  under  one  pound 
of  pressure  it  ascended  the  intestinal  canal,  and  in  a  few  seconds  reached  the 
stomach.  A  tube  was  introduced  into  the  stomach,  and  as  the  gas  escaped  it 
was  ignited  and  burned  with  a  steady  flame. 

Experiment  25.  Dog,  weight  eighteen  pounds  (8  kilograms)."  Rectal 
insufflation  of  hydrogen  gas,  the  dog  being  fully  under  the  influence  of  an 
anaesthetic.  The  colon  and  caecum  were  only  slightly  distended  when  the  gas, 
under  one-quarter  of  a  pound  (.1  kilogram)  of  pressure,  passed  the  ileo-cagcal 
valve.  Under  one  pound  (.45  kilogram)  of  pressure,  the  abdomen  became  uni- 
formly distended  and  tympanitic,  and  when  a  tube  was  introduced  into  the 
stomach  the  escaping  gas  was  ignited  and  burned  with  a  steady  flame  as  long 
as  the  pressure  was  continued. 

Experiment  26.  Dog,  weight  twenty  pounds  (9  kilograms).  Animal  ether- 
ized, and  when  completely  relaxed  hydrogen  gas  was  inflated  per  rectum,  and 
passed  the  ileo-caecal  valve  under  a  pressure  of  half  a  pound  (.2  kilogram).  The 
stomach  became  distended  under  a  pressure  of  one  pound  and  a  half  (.7  kilo- 
gram), and  on  the  introduction  of  a  tube  the  escaping  gas  was  ignited  and 
burned  with  a  continuous  flame  as  long  as  the  manometer  registered  half  a 
pound  (.2  kilogram)  of  pressure. 

In  all  animals  where  the  insufflation  was  not  complicated  by 
abdominal  section,  no  unpleasant  symptoms  followed  the  experiments. 
All  of  the  animals  recovered  as  rapidly  as  after  an  ordinary  ether  nar- 
cosis.    In  all  of  the  experiments  the  pressure  fell  rapidly  after  the 


RESISTANCE   OF  STOMACH   TO   DIASTALT1C  FORCE.  489 

ileo-crecal  valve  had  been  opened,  but  the  pressure  had  again  to  be 
increased  before  the  gas  reached  the  stomach.  It  usually  required 
one-half  to  one  pound  more  pressure  to  force  gas  through  the  entire 
alimentary  canal  than  when  it  was  forced  only  through  the  ileo-caecal 
valve.  Whenever  it  becomes  desirable  to  conduct  the  hydrogen  gas 
a  considerable  distance  along  the  intestines,  or  through  the  entire 
alimentary  canal,  it  is  exceedingly  important  to  proceed  slowly  with 
the  inflation,  as  under  slow  distention  half  a  pound  (.2  kilogram)  of 
pressure  will  accomplish  in  time  a  greater  degree  of  distention  than 
four  times  this  amount  of  pressure  if  the  force  is  applied  quickly, 
and  only  for  a  short  time,  and  is  attended  by  much  less  risk  of 
injury  to  the  coats  of  the  intestines.  I  am  quite  convinced  that  in 
the  dog,  rectal  insufflation  of  hydrogen  gas  made  under  a  pressure  of 
one-quarter  of  a  pound,  if  made  veiy  slowly,  the  abdominal  walls 
being  completely  relaxed  by  an  anaesthetic,  will  not  only  overcome 
the  resistance  offered  by  the  ileo-csecal  valve,  but  will  prove  sufficient 
to  force  the  gas  through,  the  whole  length  of  the  alimentary  canal. 

I  have  already  sufficiently  demonstrated  the  permeability  of  the 
ileo-crecal  valve  and  the  entire  alimentary  canal  in  animals  and  man 
to  rectal  insufflation  of  air  and  gas,  and  I  shall  now  endeavor  to 
establish  the  safety  of  this  procedure  as  a  diagnostic  and  therapeutic 
measure  by  showing: 

II.    The  Resistance  of  Different  Portions  of  the  Gastro- 
intestinal Canal  to  Diastaltic  Force. 

i.     Stomach. 

Experiment  27.  Large,  healthy,  adult  dog.  Experiment  made  immedi- 
ately after  death.  Stomach  in  situ.  (Esophagus  tied  and  distention  made 
with  a  force  pump  from  pyloric  orifice,  the  organ  being  rapidly  dilated  with 
air.  When  the  manometer  registered  eight  and  one-half  pounds  (3.9  kilo- 
gram.-) of  pressure,  the  stomach  was  distended  at  least  eight  times  its  normal 
size,  when  a  rent  in  the  peritoneal  covering  an  inch  and  a  half  in  length 
parallel  to,  and  near  the  omental  attachment,  occurred. 

Experiment  28.  Middle-aged  man,  died  of  sepsis.  The  whole  gastroin- 
testinal canal  showed  marked  evidences  of  septic  gastro-entero-colitis,  the 
mucous  membrane  being  softened,  very  vascular,  and  dotted  with  numerous 
hemorrhagic  infarcts.  Organ  in  situ  inflated  with  air  in  the  same  manner  as 
in  lasl  experiment.  Longitudinal  rupture  of  peritoneal  coat  along  anterior 
ce  under  two  and  one-half  pounds  of  pressure  (1.1  kilograms),  and  when 
it  was  increased  u>  three  pounds  (1.4  kilograms),  the  whole  thickness  of  the 
wall  at  the  lesser  curvature  ruptured. 


490 


EXPERIMENTAL  SURGERY. 


2.     Small   Intestines. 


Experiment  29.  Subject  same  as  in  experiment  28.  Lower  portion  of 
ileum  under  five  pounds  (2.3  kilograms)  of  pressure,  became  emphysematous 
along  mesenteric  attachment,  and  ruptured  completely  as  soon  as  the  mano- 
meter registered  five  and  three-fourths  pounds  (2.6  kilograms)  of  pressure. 

Experiment  30.  Dog,  weight  twenty  pounds  (0  kilograms).  Immediately 
after  death  the  lower  part  of  the  ileum,  with  mesenteric  attachment  intact, 
was  gradually  distended  and  remained  intact  until  a  piessure  of  ten  pounds 
(4.5  kilograms)  was  reached,  when  air  escaped  between  the  two  serous  layers 
of  the  mesentery,  showing  that  minute  ruptures  at  numerous  points  had  taken 
place.  When  the  distention  had  reached  its  maximum,  the  segment  of  bowel 
inflated  was  elongated  twice  its  normal  length. 

Experiment  31.  Upper  portion  of  ileum  of  same  animal  when  distended 
to  its  utmost  gave  way  under  a  pressure  of  eight  pounds  (3.ti  kilograms),  the 
peritoneal  coat  on  convex  side  rupturing  to  the  extent  of  two  inches  (51  mm.) 
parallel  to  the  axis  of  the  bowel. 

Experiment  32.  The  middle  portion  of  the  small  intestines,  when  sub- 
jected to  a  pressure  of  eight  pounds  (3.6  kilograms),  sustained  a  longitudinal 
rupture  of  the  peritoneum  on  convex  surface,  and  the  remaining  tunics  gave 
way  when  the  pressure  was  increased  to  nine  pounds  (4.1  kilograms). 

3.     Colon. 

Experiment  33.  Subject  same  as  experiments  28  and  29.  Experiment  was 
made  twenty-four  hours  after  death.  Colon  and  caecum  apparently  very  much 
softened  and  mucous  membrane  in  a  state  of  inflammation.  One  foot  (30  cm.) 
of  the  transverse  colon  isolated  and  gradually  distended,  when  the  peri- 
toneal coat  along  the  border  of  one  of  the  longitudinal  bands  ruptured  under 
a  pressure  of  two  pounds  and  a  half  (1.1  kilograms).  The  peritoneal  lacera- 
tion became  very  extensive  before  the  remaining  tunics  ruptured  under  a 
pressure  of  four  pounds  (1.8  kilograms). 

Experiment  34.  Dog,  weight  eighteen  pounds  (8.2  kilograms).  Imme- 
diately after  death  the  ileum  was  tied  j  ust  above  the  caecum,  and  the  inflation 
made  per  rectum.  Air  was  pumped  in  gradually  with  a  force-pump  and  when 
the  pressure  reached  ten  pounds  and  a  half  (4.8  kilograms),  air  escaped 
between  the  peritoneal  layers  of  the  meso-colon;  at  this  stage  the  longitudinal 
distention  of  the  bowel  exceeded  twice  its  normal  length. 

Experiment  35.  Dog,  weight  twenty-three  pounds  (10.4  kilograms). 
Experiment  the  same  as  the  preceding.  Air  was  pumped  in  rapidly  until  the 
mercury  gauge  registered  ten  and  a  half  pounds  (4.8  kilograms)  of  pressure, 
when  the  sigmoid  flexure  on  its  free  surface  gave  way  with  a  loud  report,  the 
rent  being  about  one  inch  and  a  half  (38  mm.)  in  length. 

Experiment  36.  Dog,  weight  eighteen  pounds  (8.2  kilograms).  Entire 
colon  distended  by  rectal  inflation  of  air,  the  ileum  being  tied  just  above  the 
ileo-caecal  valve.  Under  a  pressure  of  six  pounds  (2.7  kilograms),  the  peri- 
toneum ruptured  in  a  longitudinal  direction,  opposite  the  meso-colon,  and 
the  remaining  tunics  gave  way  a  little  later,  under  the  same  pressure. 


DISTENTION   OF   GASTRO-INTESTINAL    CANAL.  491 

These  experiments  are  of  the  greatest  importance  in  showing 
that  the  pressure  which  was  found  necessary  to  apply  in  rapturing 
a  healthy  intestine,  was  greatly  in  excess  of  that  which  is  required 
to  force  air  through  the  ileo-csecal  valve,  or  even  the  whole  length 
of  the  alimentary  canal.  It  only  requires  from  one-quarter  of  a 
pound  to  a  pound  and  a  half  (.1  to  .7  kilogram)  of  pressure  to  force 
air  through  the  ileo-csecal  valve,  and  from  half  a  pound  to  two 
pounds  and  a  half  (.2  to  1.1  kilograms)  to  force  it  from  anus  to 
mouth,  while  even  the  weakest  portion  of  the  gastro- intestinal  canal 
effectually  resisted  a  distending  force  of  from  eight  to  ten  pounds 
(3.6  to  4.5  kilograms). 

The  experiments  on  the  human  cadaver,  where  the  resisting 
power  of  the  gastro-intestinal  canal  to  diastaltic  force  was  greatly 
reduced  by  ante-mortem  pathological  changes,  show  that  under  such 
circumstances  it  would  have  been  safe  to  resort  to  inflation,  as  the 
pressure  required  to  rapture  the  colon  or  small  intestines  exceeded 
that  which  has  been  found  adequate  to  force  air  or  gas  beyond  the 
ileo-csecal  valve,  or  even  the  entire  length  of  the  alimentary  canal. 
When  an  intestine  is  slowly  distended  to  its  utmost  capacity  by 
inflation  of  air  or  gas,  and  the  pressure  is  maintained  uninterruptedly, 
rupture  occurs  at  one  of  two  points ;  either  a  longitudinal  laceration 
of  the  peritoneal  coat  takes  place  on  the  convex  surface  of  the  bowel 
opposite  the  mesenteric  attachment,  or  minute  raptures  on  the 
mesenteric  side  give  rise  to  extravasation  of  air  or  gas  between  the 
two  serous  layers  of  the  mesentery.  In  either  case,  if  the  pressure 
is  increased,  complete  rupture  takes  place  at  the  point  where  the 
laceration  first  commenced. 

III.     Distention    of    Gastro-intestinal    Canal    by    Rectal 
Insufflation  of  Hydrogen  Gas. 

In  this  section  will  be  found  an  account  of  the  experiments 
which  were  made  preliminary  to  the  practical  application  of  the 
hydrogen  gas  test  as  a  diagnostic  measure  in  penetrating  wounds 
of  the  abdomen,  and  which  furnish  only  so  many  more  demonstra- 
tions of  the  permeability  of  the  ileo-csecal  valve  and  the  entire 
alimentary  canal  to  rectal  inflation  of  hydrogen  gas. 

Experiment  37.  Dog,  weight  fifteen  pounds  (6.8  kilograms).  Under  ether 
anaesthesia,  hydrogen  gas  from  rubber  balloon  was  slowly  forced  into  the 
rectum  until  t he  entire  anterior  abdominal  wall  had   become  uniformly  dis- 


492  EXPERIMENTAL  SURGERY. 

tended  and  tympanitic,  when  the  distended  stomach  was  punctured  with  a 
large  aspirator  needle  and  gas  escaped  in  a  steady  stream,  which  when  ignited 
burned  with  a  continuous  flame.  After  a  considerable  portion  of  the  gas  had 
been  evacuated  in  this  manner  the  upper  abdominal  region  receded,  and  the 
flame  was  extinguished.  The  animal  recovered  without  any  untoward 
symptoms. 

Experiment  38.  Dog,  weight  seventeen  pounds  (7.7  kilograms).  Without 
anaesthesia  hydrogen  gas  was  inflated  per  rectum  until  it  escaped  through  a 
tube  which  had  been  introduced  into  the  stomach.  As  it  escaped  from  the 
stomach  tube  it  was  ignited  and  burned  with  a  large  blue  flame.  The  abdom- 
inal muscles  were  so  rigid  that  distention  was  never  well  marked,  and  the 
inflation  required  a  good  deal  more  force  than  in  animals  where  muscular 
rigidity  had  been  overcome  by  an  anaesthetic.  The  dog  remained  perfectly 
well  after  the  experiment,  and  in  a  few  hours  the  remaining  tympanites  had 
disappeared. 

Experiment  39.  Dog,  weight  thirty-five  pounds  (15.8  kilograms).  No 
anaesthetic  used.  On  account  of  rigidity  of  abdominal  muscles  it  required 
persistent  efforts  to  force  hydrogen  gas  from  rubber  balloon  per  rectum 
through  the  whole  alimentary  canal.  As  soon  as  the  stomach  had  become 
distended  by  the  gas,  the  animal  vomited;  at  the  same  time  gas  escaped 
by  repeated  eructations.  The  animal  manifested  no  signs  of  suffering  after 
the  experiment. 

Experiment  40.  Dog,  weight  twenty-seven  pounds  (12.2  kilograms). 
Under  anaesthesia  hydrogen  gas  was  inflated  per  rectum  until  it  escaped 
through  tube  which  had  been  introduced  into  the  stomach;  a  lighted  taper 
was  applied  to  the  free  end  of  the  tube,  and  the  gas  ignited  and  burned  with 
the  characteristic  blue  flame. 

Experiment  41.  Large  Newfoundland  dog.  Under  anaesthesia  a  duoden- 
ostomy  was  made,  and  hydrogen  gas  injected  per  rectum  and  ignited  as  it 
escaped  from  a  rubber  tube,  which  had  been  inserted  into  the  distal  portion 
of  the  bowel  through  the  fistula. 

Experiment  42.  Adult  male;  abdominal  organs  healthy;  no  anaesthesia. 
Inflation  of  hydrogen  gas  per  rectum.  The  gas  was  stored  in  a  four-gallon 
(9  litres)  rubber  balloon  and  was  forced  into  the  rectum  by  compression.  As 
the  distention  progressed  the  colon  could  be  distinctly  mapped  out  from 
sigmoid  flexure  to  caecum  by  inspection  and  percussion.  As  soon  as  the 
caecum  had  become  visibly  prominent,  a  stethoscope  was  applied  over  the  ileo- 
caecal  region,  and  as  the  valve  became  incompetent  by  overdistention  of 
caecum,  a  distinct  gurgling  sound  could  be  heard  as  the  gas  entered  the  ileum. 
Whenever  inflation  was  arrested  the  gurgling  sound  disappeared,  but  was 
heard  again  whenever  the  ileo-caecal  valve  was  opened  by  renewed  inflation. 

Distention  of  the  small  intestines  was  attended  by  resonance 
and  prominence  of  umbilical  and  hypogastric  regions.  The  incom- 
petency of  the  ileo-caecal  valve  was  invariably  announced  by  a 
reduction  in  the  pressure.     The  patient  complained  of  a  sensation 


DISTENTION   OF  GASTRO-INTESTINAL   CANAL.  493 

of  distention  in  the  umbilical  region  and  intermittent  colicky  pains 
which,  however,  disappeared  completely  after  a  few  hours.  The 
pain  appeared  to  be  less  severe  than  after  similar  experiments  with 
inflation  of  air. 

Experiment  43.  Young  man  in  comparatively  good  health.  Inflation 
same  as  in  preceding  experiment.  Auscultation  over  ileo-csecal  valve  revealed 
the  same  sounds  as  the  gas  escaped  from  the  colon  into  the  ileum.  The  sound 
seemed  to  vary  somewhat  according  to  the  size  of  the  opening  in  the  valve 
and  the  force  used  in  making  the  inflation,  and  always  disappeared  as  the 
valve  closed  after  suspension  of  inflation.  The  colicky  pains  subsided  as 
the  small  intestines  emptied  themselves  of  their  new  contents.  The  assistant 
who  compressed  the  rubber  balloon  was  always  able  to  announce  the  beginning 
of  the  incompetency  of  the  ileo-csecal  valve,  by  experiencing  a  sudden 
diminution  in  the  pressure. 

Experiment  44.  Adult  male,  suffering  from  gastric  catarrh.  Hydrogen 
gas  inflation  per  rectum  to  extent  of  causing  great  distention  of  abdomen, 
which  caused  the  hepatic  dullness  to  ascend  at  least  two  inches.  Auscultatory 
signs  the  same.  Sharp  colicky  pains  in  the  umbilical  region  were  relieved  by 
a  free  escape  of  gas  through  rectum. 

Experiment  45.  Hysterical  female.  Abdomen  flat  and  dull  on  percussion 
from  umbilicus  to  pubes;  no  resonance  over  sigmoid  flexure.  Rectal  inflation 
with  hydrogen  gas.  Compression  of  rubber  balloon  corresponding  to  only 
one-fourth  pound  (.1  kilogram)  of  pressure  readily  dilated  the  whole  colon,  its 
course  being  indicated  by  a  distinct  prominence  and  tympanitic  resonance 
from  sigmoid  flexure  to  caecum.  Under  the  same  pressure  the  gas  escaped 
with  little  or  no  resistance  through  the  ileo-csecal  valve  from  the  colon  into 
the  ileum,  the  occurrence  being  attended  by  the  characteristic  auscultatory 
sounds  and  followed  by  distention  and  resonance  of  space  from  umbilicus  to 
pubes.  Amount  of  gas  inflated  about  four  litres.  The  patient  complained  of 
some  pain  in  the  region  of  the  splenic  flexure  of  the  colon  during  the  disten- 
tion of  the  colon,  and  later  of  slight  intermittent  pain  in  the  region  of  the 
umbilicus. 

Experiment  46.  Middle-aged  woman,  suffering  from  retroversion  of  the 
uterus.  Abdomen  flaccid  and  dull  on  percussion  in  the  median  line  from 
umbilicus  to  pubes.  Rectum  distended  with  hardened  fasces.  Hydrogen  gas 
inflated  in  the  usual  manner.  The  mercury  gauge  registered  two  and  a  half 
pounds  (1.1  kilograms)  of  pressure  before  the  gas  reached  the  sigmoid  flexure, 
after  this  it  fell  tb  one  pound  (.45  kilogram),  and  the  inflation  progressed 
without  any  further  resistance.  As  soon  as  the  gas  passed  through  the  ileo- 
csecal  valve  the  pressure  fell  to  three-quarters  of  a  pound  (.3  kilogram),  and 
remained  so  during  the  inflation  of  the  small  intestines,  slight  variations 
marking  the  opening  and  closing  of  the  ileo-csecal  valve.  As  the  umbilical 
and  hypogastric  regions  became  prominent  and  tympanitic  the  patient  com- 
plained of  a  griping  pain.  About  eight  litres  of  gas  were  injected.  A  few 
hours  after  the  experiment  all  symptoms  had  disappeared. 


494  EXPERIMENTAL  SURGERY. 

Experiment  47.  Female  recently  operated  on  for  laceration  of  perineum. 
Rectum  empty.  Abdomen  flaccid ;  umbilical,  hypogastric,  and  right  iliac 
regions  dull  on  percussion.  The  inflation  was  made  very  slowly  and  the 
pressure  never  exceeded  one  pound  (.45  kilogram).  As  the  large  intestine 
became  distended  the  transverse  colon  came  plainly  into  view.  On  ausculta- 
tion over  the  ileo-caecal  valve  the  escape  of  gas  into  the  ileum  was  marked  by 
a  blowing  sound,  which  was  increased  or  diminished  in  pitch  by  the  degree  of 
pressure.  As  the  lower  portion  of  the  small  intestines  became  distended  the 
lower  part  of  the  abdomen  became  prominent  and  tympanitic,  and  the  patient 
complained  of  colicky  pains.  About  three  litres  of  gas  were  inflated.  In  half 
an  hour  the  patient  appeared  as  well  as  before  inflation. 

Experiment  48.  Middle-aged  physician  suffering  from  typhlitis.  This 
was  the  second  attack,  and  the  acute  symptoms  had  subsided.  Over  the  caecum 
a  circumscribed  area  of  dullness  and  tenderness.  On  palpation  it  appeared 
as  though  the  swelling  were  adherent  to  the  anterior  abdominal  wall.  The 
area  of  dullness  was  outlined  externally  by  pencil  marks,  before  inflation  was 
commenced.  As  the  colon  became  distended  under  a  pressure  of  one-fourth 
of  a  pound  (.1  kilogram),  the  circumscribed,  indurated  region  became  more 
prominent,  imparting  to  the  palpating  fingers  the  feeling  of  hardness,  but  on 
percussion  it  was  resonant,  showing  conclusively  that  the  inflamed  and  indu- 
rated wall  of  the  caecum  had  been  lifted  forward  by  the  pressure  of  the  gas. 
Under  the  same  pressure  the  gas  escaped  in  a  continuous  stream  into  the 
ileum,  its  passage  through  the  ileo-caecal  valve  being  attended  by  a  well- 
marked  blowing,  gurgling  sound.  The  patient  felt  the  entrance  of  gas  into 
the  ileum  distinctly,  and  complained  soon  after  of  a  slight  colicky  pain  in  the 
umbilical  region.  The  space  between  umbilicus  and  pubes,  which  before  infla- 
tion was  completely  dull  on  percussion,  now  became  more  prominent  and 
tympanitic.     Only  two  litres  of  gas  were  used  in  this  experiment. 

Experiment  49.  Young  physician  in  perfect  health.  Region  between 
umbilicus  and  pubes  perfectly  dull  on  percussion,  also  left  iliac  fossa.  Infla- 
tion of  four  litres  of  hydrogen  gas  under  one-third  of  a  pound  (.15  kilogram) 
pressure.  The  outlines  of  the  distended  colon  could  be  clearly  seen  and 
marked  out  by  percussion  before  the  gas  escaped  into  the  small  intestines. 
The  passage  of  gas  through  the  ileo-caecal  valve  was  again  attended  by  a  well- 
marked  gurgling  sound,  after  which  the  entire  abdomen  became  prominent 
and  tympanitic.  The  patient  felt  a  sensation  of  distention  during  the  infla- 
tion of  the  colon,  and  as  the  small  intestines  became  distended,  complained 
of  griping  pains.  Gas  escaped  freely  by  eructations  and  per  rectum,  which 
soon  relieved  the  colicky  pains  in  the  umbilical  region.      . 

Experiment  50.  Medical  student  in  robust  health.  Region  from  umbilicus 
to  pubes  flat  on  percussion,  while  the  course  of  the  entire  colon  was  tympan- 
itic. Rectal  inflation  with  hydrogen  gas.  When  the  resistance  of  the  ileo- 
csecal  valve  was  overcome  the  mercury  gauge  registered  one-half  pound  (.2 
kilogram)  of  pressure.  The  passage  of  gas  through  the  ileo-caecal  valve  was 
attended  by  a  gurgling  sound  which  was  heard  at  some  distance  by  a  number 
of  persons  present  in  the  room.    Later  a  continuous  blowing  (almost  amphoric) 


DISTENTION   OF  GASTRO-INTESTINAL   CANAL.  495 

sound  could  be  heard  over  the  ileo-caecal  valve.  The  subject  of  the  experi- 
ment was  conscious  of  the  passage  of  gas  from  colon  into  ileum,  and  soon 
after  complained  of  a  colicky  pain  which  he  referred  to  the  umbilical  region. 
The  whole  abdomen  became  uniformly  distended  and  tympanitic  on  percus- 
sion, and  the  distress  caused  by  the  great  distention  was  only  relieved  by  a 
free  escape  of  gas  by  eructations  and  through  the  rectum.  Four  litres  of  gas 
were  used  in  this  experiment. 

Experiment  51.  Young  physician  in  good  health.  Rectal  inflation  of  four 
litres  of  hydrogen  gas  under  a  pressure  of  only  one-third  pound  (.15  kilogram). 
Distention  of  colon  well-marked  previous  to  escape  of  gas  through  the  ileo- 
caecal  valve.  As  soon  as  the  gas  entered  the  ileum  the  middle  and  lower 
portion  of  the  abdomen  became  distended  and  tympanitic.  The  inflation  was 
continued  until  the  stomach  became  distended  and  gas  escaped  by  eructation. 
The  subject  of  the  experiment  complained  of  quite  severe  colicky  pains  as 
long  as  the  small  intestines  remained  distended  by  gas. 

Experiment  52.  The  writer  of  this  paper,  being  desirous  of  experiencing 
himself  the  sensations  which  would  be  caused  by  inflation  of  hydrogen  gas, 
submitted  himself  to  experimentation  under  a  pressure  of  one-half  pound  (.2 
kilogram).  Nearly  six  litres  of  gas  were  inflated  per  rectum.  The  distention 
of  the  colon  caused  simply  a  feeling  of  distention  along  its  course,  but  as 
soon  as  the  gas  escaped  into  the  ileum  colicky  pains  were  experienced,  which 
increased  as  insufflation  advanced,  and  only  ceased  after  all  the  gas  had 
escaped,  an  hour  and  a  half  later.  When  the  intestines  and  the  stomach  had 
become  fully  distended,  the  feeling  of  distention  was  distressing,  and  was 
attended  by  a  sensation  of  faintness  which  caused  a  profuse  clammy  perspi- 
ration. A  great  deal  of  the  gas  escaped  by  eructation,  which  was  followed 
by  great  relief.  The  colicky  pain  attending  inflation  of  the  small  intestines  by 
air  or  gas,  was  evidently  caused  by  increased  peristaltic  action  of  the  bowels 
in  their  attempt  to  expel  their  contents,  as  it  always  assumed  an  intermittent 
type  and  subsided  promptly  after  the  escape  of  the  gas. 

In  none  of  these  experiments  did  the  pressure  in  overcoming 
the  resistance  offered  by  the  ileo-csecal  valve  exceed  one  pound  (.45 
kilogram),  and  often  a  steady,  long-continued  pressure  of  one-fourth 
or  one -third  of  a  pound  (.1  to  .15  kilogram)  sufficed.  Every  time 
the  ileo-csecal  valve  was  rendered  incompetent  by  distention  of  the 
cpecum,  the  pressure  was  promptly  diminished  owing  to  the  escape 
of  gas  from  the  colon  into  the  ileum.  In  the  experiment  where  the 
inflation  was  made  in  a  case  of  typhlitis,  the  ileocecal  valve  offered 
no  resistance,  and  the  gas  escaped  freely  into  the  ileum.  The  valve 
in  all  probability  had  been  rendered  partially  or  completely  incom- 
petent during  the  course  of  local  inflammation,  or  the  indurated, 
thickened  walls  of  the  coecum,  when  distended  during  the  inflation, 
were  better  adapted  to  effect  incompetency  of   the  valve.      These 


496  EXPERIMENTAL  SURGERY. 

experiments  also  furnish  strong  proof  of  the  fact  that  inflation,  to  be 
safe  and  effective,  should  be  done  very  slowly  under  a  low,  steady 
pressure,  continued  only  for  a  short  time;  and  is  attended  by  no 
risks  whatever  of  rupturing  a  healthy  intestine  and,  when  cautiously 
practiced,  can  be  resorted  to  even  in  cases  where  the  resisting 
power  of  the  intestinal  wall  has  been  diminished  by  antecedent 
pathological  processes. 

As  I  was  searching  for  an  innocuous,  non- irritating  gas  which, 
when  inflated  into  the  gastro-intestinal  canal,  would  escape  into  the 
peritoneal  cavity  in  case  a  wound  or  perforation  existed,  and  had 
decided  on  trying  hydrogen  gas,  it  became  necessary  to  study 
experimentally  the  effect  of  this  gas  on  the  different  tissues  of  the 
living  body.  The  numerous  inflation  experiments  on  man  and  dogs 
have  demonstrated  the  safety  of  pure  hydrogen  gas  when  employed 
in  this  manner,  as  not  in  a  single  instance  were  any  immediate  or 
remote  toxic  symptoms  observed  which  could  be  referred  to  absorp- 
tion of  the  gas;  hence  we  have  the  assurance  that  the  inflation  of  a 
large  quantity  of  hydrogen  gas  is  unattended  by  any  risk  whatever 
as  far  as  intoxication  is  concerned.  The  following  experiments 
also  show  the  innocuity  and  non-irritating  qualities  of  hydrogen  gas 
when  brought  in  contact  with  the  tissues  most  susceptible  to  inflam- 
matory reaction  in  the  living  body;  at  the  same  time  they  show  that 
hydrogen  gas  is  removed  by  absorption  in  a  comparatively  short 
time,  when  injected  into  serous  cavities  or  into  the  subcutaneous 
connective  tissue: 

IT.    Hydrogen  Gas  is  Innocuous  and  Non-Irritating  when 

Brought  in  Contact  with  Living  Tissues  and  is 

Promptly  Removed  by  Absorption. 

I.     Peritoneal  Cavity. 

Experiment  53.  Dog,  weight  forty-five  pounds.  A  circumscribed  spot  to 
the  right  of  the  linea  alba  was  shaved  and  thoroughly  disinfected,  and  through 
this  space  a  well  disinfected,  medium  sized  trocar  was  plunged  into  the  peri- 
toneal cavity.  To  the  cannula  of  the  trocar  the  rubber  tube  of  the  inflation 
balloon  charged  with  hydrogen  gas  was  attached,  and  the  whole  peritoneal 
cavity  filled  with  gas  by  compressing  the  balloon.  About  four  litres  of  gas 
were  injected.  No  gas  escaped  upon  the  withdrawal  of  the  cannula  and  the 
puncture  was  sealed  with  cotton  and  iodoform  collodium.  The  animal 
appeared  to  suffer  but  little  pain,  and  the  next  day  the  tympanites  had  dis- 
appeared and  the  dog  was  as  frisky  and  lively  as  before  the  inflation.      Two 


RECTAL  INSUFFLATION  IN   GUNSHOT    WOUNDS.  4{J7 

days  after  the  experiment  was  made  the  dog  was  killed  and  the  peritoneal 
cavity  carefully  examined.  Not  a  trace  of  the  gas  remained  and  the  peritoneum 
throughout  presented  a  normal  appearance. 

2.     Pleural  Cavity. 

Experiment  54.  Dog,  weight  twenty-five  pounds.  After  thorough  dis- 
infection, an  aseptic  hollow  needle  was  inserted  between  the  seventh  and 
eighth  ribs  in  the  axillary  line  into  the  left  pleural  cavity,  and  hydrogen  gas 
from  rubber  balloon  forced  through  it  until  the  pleural  cavity  was  thoroughly 
distended.  On  making  a  physical  examination  of  the  chest  at  this  time  the 
apex  of  the  heart  was  found  to  the  right  of  the  sternum;  vesicular  breathing 
on  left  side  absent;  abnormal  resonance  on  percussion  of  this  side.  The  res- 
pirations became  superficial  and  greatly  increased  in  frequency.  On  with- 
drawing the  needle  no  gas  escaped  externally,  but  a  circumscribed  subcutaneous 
emphysema  which  appeared,  showed  that  some  of  the  gas  had  escaped  through 
the  puncture  in  the  pleura  into  the  subcutaneous  connective  tissue.  Twenty- 
four  hours  after  the  inflation  the  dog  appeared  to  be  in  perfect  health.  The 
normal  relations  in  the  chest  had  become  restored  and  the  subcutaneous 
emphysema  was  less  extensive.  The  animal  was  kept  under  observation  for 
a  considerable  length  of  time,  but  at  no  time  could  symptoms  of  pleuritis  be 
detected. 

3.     Subcutaneous  Cellular  Tissue. 

Experiment  55.  Old  dog,  weight  forty-three  pounds.  A  small,  perfectly 
aseptic  trocar  was  inserted  through  the  skin  into  the  loose  cellular  tissue  in 
the  right  inguinal  region,  and  through  the  cannula  two  litres  of  gas  were 
injected,  the  gas  distributing  itself  through  the  loose  connective  tissue  over 
a  large  surface  of  the  body.  Upon  the  withdrawal  of  the  cannula  the  puncture 
was  hermetically  sealed  with  iodoform  collodium  and  cotton.  The  subcuta- 
neous emphysema  disappeared  completely  in  forty-eight  hours,  and  no  traces 
of  inflammation  could  be  found  at  the  point  of  puncture,  or  at  any  place 
where  the  gas  had  come  in  contact  with  the  tissues. 

Experiment  56.  Dog,  weight  twenty-five  pounds.  Subcutaneous  inflation 
of  two  litres  of  hydrogen  gas  through  the  cannula  of  a  small  trocar  into  the 
left  side  of  the  chest.  The  subcutaneous  emphysema  reached  from  the  clavicle 
and  axilla  on  that  side  to  the  crest  of  the  ilium,  the  gas  at  some  points  elevat- 
ing the  skin  at  least  four  inches  from  the  subjacent  tissues.  The  gas  was 
absorbed  somewhat  more  slowly  than  in  the  preceding  experiment,  but  three 
days  after  the  inflation  no  trace  of  emphysema  could  be  detected,  and  the 
subcutaneous  connective  tissue  was  as  pliable  and  movable  as  before  the 
inflation. 

V.    Rectal  Insufflation  of  Hydrogen  Gas  in  the  Diagnosis 
of  Penetrating  Gunshot  Wounds  of  the  Abdomen. 

In  these  experiments  the  animals  were  strapped  on  one   of 
Pasteur's  operating  tables.     Abdomen  shaved,  and  after  complete 


498  EXPERIMENTAL   SURGERY. 

etherization  the  shooting  was  done  at  short  range  with  a  thirty-two 
calibre  revolver.  Inflation  of  hydrogen  gas  was  practiced  immedi- 
ately after  the  shot  was  fired,  and  after  its  diagnostic  value  was 
carefully  studied,  the  abdomen  was  opened  and  its  contents  exam- 
ined for  visceral  injuries.  In  all  cases  where  the  colon  was  perforated, 
inflation  could  be  done  under  very  slight  pressure,  as  the  gas  readily 
escaped  into  the  peritoneal  cavity,  and  from  there  through  the  bullet 
wound  in  the  abdominal  wall,  where  it  was  ignited  as  it  escaped.  As 
it  is  not  my  object  at  present  to  give  the  result  of  the  operative  treat- 
ment, the  experiments  will  only  be  described  in  reference  to  diagnosis 
as  verified  by  abdominal  section;  but  in  every  case  an  attempt  was 
made  to  save  the  life  of  the  animal  by  operative  treatment,  and  in  a 
few  instances  the  efforts  were  rewarded  by  success. 

Experiment  57.  Dog,  weight  thirty  pounds.  The  abdomen  was  opened 
by  an  incision  through  the  linea  alba  and  a  coil  of  the  small  intestine  was 
drawn  forward  into  the  wound,  and  an  incision  half  an  inch  (13  mm.)  in 
length  was  made  on  the  convex  side  and  the  intestine  returned.  A  small  glass 
tube  was  inserted  into  lower  angle  of  wound,  and  the  rest  of  the  wound  closed 
by  sutures.  About  two  litres  of  hydrogen  gas  were  inflated  per  rectum,  when 
the  gas  escaped  through  the  glass  tube,  and  when  ignited  burned  with  a 
continuous  steady  blue  flame  as  long  as  the  inflation  was  continued.  The 
wound  was  opened  and  a  small  quantity  of  gas  was  found  in  the  peritoneal 
cavity.  The  whole  intestinal  tract  below  the  visceral  wound  was  found 
moderately  distended  by  gas,  while  above  the  wound  the  intestine  was  normal 
in  size. 

Experiment  58.  Dog,  weight  fifteen  pounds.  When  the  dog  was  com- 
pletely under  the  influence  of  ether,  hydrogen  gas  was  forced  from  anus  to 
mouth,  and  while  the  abdomen  was  still  moderately  distended  the  animal  was 
shot  in  the  abdomen,  the  bullet  being  directed  transversely  from  the  point  of 
entrance  on  the  side  of  the  abdomen  two  inches  (5  cm.)  to  the  right  of  the 
median  line,  and  on  a  level  with  the  umbilicus.  On  appliying  a  lighted  taper 
to  wound  of  entrance,  and  compressing  the  abdomen,  hydrogen  gas  escaped 
and  was  ignited.  When  the  inflation  was  resumed  the  gas  burned  with  a 
continuous  flame  at  the  wound  of  entrance.  The  abdomen  was  then  opened 
and  two  perforations  in  the  stomach  were  found,  one  on  the  anterior  surface 
near  the  pylorus,  and  the  other  on  posterior  surface  at  the  cardiac  extremity, 
about  an  inch  above  the  omental  attachment.  The  distention  of  the  stomach 
by  hydrogen  gas  had  brought  this  organ  within  range  of  the  track  of  the 
bullet. 

Experiment  59.  Dog,  weight  twenty  pounds.  Under  complete  anaesthesia 
the  animal  was  shot  in  the  abdomen,  the  bullet  taking  the  same  direction  as  in 
the  previous  experiment,  only  that  the  track  was  about  an  inch  (2.5  cm.) 
above  the  umbilicus.      Immediately   after  the  shooting  hydrogen  gas  was 


RECTAL  INSUFFLATION  IN  GUNSHOT   WOUNDS.  499 

inflated  per  rectum,  and  its  presence  in  the  abdominal  cavity  became  evident 
by  a  marked  tympanites,  absence  of  liver  dullness,  and  later  by  a  localized 
emphysema  around  the  wound  of  entrance.  As  the  pressure  was  continued 
bubbles  of  gas  escaped,  and  on  applying  a  lighted  taper,  ignited  with  a  feeble 
explosive  report.  The  abdomen  was  opened,  and  the  stomach  showed  two 
perforations,  one  just  above  the  omental  attachment  near  the  pylorus,  and  the 
other  on  the  same  level  at  the  cardiac  extremity.  Little  haemorrhage,  and  no 
extravasation  of  contents  of  stomach. 

Experiment  60.  Dog,  weight  thirty  pounds.  Animal  anaesthetized  and  shot 
in  abdomen  at  a  range  of  two  feet;  wound  of  entrance  two  inches  to  the  right 
of.  and  on  a  level  with  the  umbilicus.  Wound  of  exit  one  inch  above  the 
middle  of  left  crest  of  ilium.  Inflation  of  hydrogen  gas  per  rectum  soon 
caused  extensive  tympanites,  and  as  but  little  force  had  been  used,  the  con- 
clusion was  drawn  that  some  part  of  the  descending  colon  had  been  injured. 
As  the  gas  did  not  readily  escape  through  the  bullet  wounds,  a  small  cannula 
was  inserted  into  the  abdominal  cavity  through  the  wound  of  entrance,  when 
the  gas  escaped  freely  and  was  ignited.  On  opening  the  abdomen  examination 
revealed  the  following  visceral  injuries:  Two  perforations  in  the  descending 
colon;  four  in  the  ileum,  within  a  distance  of  ten  inches  of  the  ileo-caecal 
valve;  eight  in  the  upper  part  of  the  ileum,  within  the  space  of  one  foot 
(30.5  cm.)  of  the  intestine.  The  mesentery  was  perforated  at  three  points, 
and  a  number  of  mesenteric  vessels  of  considerable  size  were  severed,  which 
gave  rise  to  profuse  haemorrhage. 

Experiment  61.  Large  coach  dog.  The  animal  was  completely  etherized 
and  shot  in  the  abdomen  at  close  range.  Wound  of  entrance  midway  between 
linea  alba  and  vertebral  column  on  left  side,  a  little  below  the  level  of  the 
umbilicus;  wound  of  exit  close  to  the  last  lumbar  vertebra  over  crest  of  ilium 
on  opposite  side.  Rectal  inflation  of  hydrogen  gas  undor  slight  pressure  at 
once  produced  diffuse  tympanites,  and  the  gas  escaped  freely  through  wound 
of  entrance,  where  it  was  ignited  r.nd  burned  with  a  large  steady  blue  flame 
as  long  as  the  inflation  was  continued.  On  opening  the  abdomen  gas  escaped, 
but  inspection  showed  that  the  small  intestines  contained  no  gas,  a  condition 
which  pointed  to  the  colon  as  the  seat  of  perforation.  One  perforation  was 
found  in  the  anterior  wall  of  the  sigmoid  flexure,  and  two  perforations  in  the 
caecum.  In  the  small  intestines  two  perforations  were  found  in  the  ileum  near 
the  caecum,  and  three  in  the  upper  portion  of  the  jejunum.  Among  the  other 
organs  injured  were  the  spleen,  and  the  receptaculum  chyli;  a  number  of  per- 
forations were  found  in  the  mesentery. 

*  Experiment  62.  Large  dog.  Profound  ether  narcosis.  Shot  in  the  abdo- 
men, the  bullet  entering  on  a  level  with  the  umbilicus  and  about  one  inch  to 
the  left  of  the  median  line.  Point  of  exit  two  inches  from  spinal  column, 
and  a  little  above  the  lower  border  of  the  chest.  On  inflating  the  rectum  with 
hydrogen  gas,  hardly  any  force  was  required  to  distend  the  abdomen,  and  for 
this  reason  it  was  believed  that  the  colon  in  some  part  of  its  course  had  been 
injured.  Gas  escaped  readily  through  the  wound  of  entrance,  where  it  was 
lighted  and  burned  with   the  characteristic  blue  flame.     The  abdomen  when 


500  EXPERIMENTAL   SURGERY. 

opened  was  found  almost  completely  filled  with  blood.  The  source  of  this 
profuse  haemorrhage  was  the  right  kidney  which  showed  a  perforation  through 
the  centre.  An  examination  of  the  gastro-intestinal  canal  revealed  two 
perforations  of  the  caecum,  and  five,  of  the  small  intestines.  After  passing 
through  the  kidney  the  bullet  perforated  the  diaphragm,  traversed  the  pleural 
cavity,  and  escaped  through  the  chest  wall  two  inches  (5  cm.)  to  the  right  of 
the  spine. 

Experiment  63.  Old  dog,  weight  thirty-five  pounds.  Thoroughly  etherized 
and  shot  in  the  abdomen,  the  bullet  entering  three  inches  (7.6  cm.)  to  the  right 
of,  and  an  inch  and  a  half  (3.8  cm.)  below  the  umbilicus,  passing  almost  trans- 
versely through  the  abdominal  cavity  and  escaping  at  a  corresponding  point 
on  left  side.  Inflation  of  hydrogen  gas  was  attempted,  but  failed  on  account 
of  the  apparatus  being  out  of  order.  The  abdomen  was  opened  and  no  gas 
was  found  even  in  the  colon.  Twelve  perforations  of  the  small  intestines  were 
found,  and  a  number  of  perforations  of  the  mesentery,  which  had  caused  pro- 
fuse haemorrhage. 

Experiment  64.  Large,  black  dog.  Etherized  and  shot  in  the  abdomen; 
wound  of  entrance  three  inches  (7.6  cm.)  to  the  right  of,  and  an  inch  and  a 
half  below  the  umbilicus;  wound  of  exit  near  a  corresponding  point  on 
opposite  side,  the  bullet  taking  nearly  a  transverse  course.  Rectal  inflation  of 
hydrogen  gas  gave  a  prompt  positive  result.  The  abdomen  was  opened  and 
five  perforations  of  small  intestine  were  found,  besides  laceration  of  thoracic 
duct,  and  a  number  of  perforations  in  mesentery.  Colon  and  small  intestine 
below  the  lowest  point  of  perforation  contained  gas,  while  above  the  lowest 
perforation  the  bowel  contained  no  gas. 

Experiment  65.  Dog,  weight  twenty-five  pounds.  Under  full  anaesthesia 
the  animal  was  snot  in  the  abdomen,  the  bullet  passing  in  a  nearly  transverse 
direction  through  the  abdominal  cavity  an  inch  and  a  half  below  the  umbilicus 
from  point  of  entrance;  wound  of  exit  midway  between  linea  alba  and  spine. 
Rectal  insufflation  of  hydrogen  gas  made  under  very  low  pressure,  led  to 
rapid  distention  of  the  abdomen,  an  occurrence  which  furnished  strong 
evidence  that  the  gas  had  escaped  through  a  perforation  in  the  colon  into  the 
peritoneal  cavity.  The  gas  escaped  in  bubbles  through  the  wound  of  entrance) 
and  when  a  lighted  taper  was  held  near  the  wound,  it  burned  with  a  jet  vary- 
ing in  size.  On  opening  the  abdomen  gas  escaped  from  the  peritoneal  cavity; 
small  intestines  empty,  and  only  a  small  amount  of  gas  in  the  colon.  The 
following  intra-peritoneal  injuries  were  found:  Four  perforations  of  the 
duodenum,  two  of  the  jejunum,  and  one  of  the  caecum;  also  a  perforation 
nearly  through  the  centre  of  the  left  kidney,  laceration  of  the  receptaculum 
chyli,  and  a  number  of  perforations  in  the  mesentery.  The  bullet  was  found 
between  the  left  kidney  and  the  abdominal  wall. 

In  all  of  these  experiments  the  bullet  was  fired  through  the 
abdomen  from  side  to  side  transversely,  or  somewhat  obliquely, 
directions  which  invariably  brought  into  the  track  of  the  bullet  a 
number  of  intestinal  coils,  and  often  the  colon.      In  the  two  experi- 


RECTAL  INSUFFLATION  IN  GUNSHOT  WOUNDS.  501 

ments  where  the  track  of  the  bullet  was  a  little  higher  up,  the 
intestines  escaped,  but  the  stomach  showed  two  perforations,  one 
near  the  pyloric,  and  the  other  near  the  cardiac  extremity.  Rectal 
insufflation  of  hydrogen  gas  proved  an  infallible  test  in  every 
instance,  except  in  the  case  where  it  failed  on  account  of  the  infla- 
tion apparatus  being  out  of  order.  Contrary  to  the  experience  of 
other  experimenters,  I  found  that  faecal  extravasation  does  not 
uniformly  take  place  soon  after  gunshot  wounds  of  the  intestines; 
in  the  cases  where  I  observed  it,  some  part  of  the  colon  had  been 
wounded.  Intestinal  inflation  does  not,  therefore,  tend  to  increase 
the  frequency  of  this  occurrence,  and  must,  on  this  account,  be 
looked  upon  as  a  harmless  measure. 

Inflation,  as  a  preliminary  measure,  greatly  expedites  the  first 
step  in  the  operation  of  abdominal  section  in  cases  where  the  intes- 
tine has  been  perforated  or  injured,  as  the  gas  which  escapes  into 
the  peritoneal  cavity  separates  the  intestines  from  the  anterior 
abdominal  wall,  and  the  incision  can  be  made  safely  and  rapidly 
without  fear  of  wounding  the  intestines.  Penetrating  wounds  of 
the  abdomen,  where  the  course  of  the  bullet  is  in  an  opposite  direc- 
tion to  that  which  has  been  described  in  the  preceding  experiments, 
that  is,  in  an  anteroposterior  direction,  may  not  implicate  the  intes- 
tines at  all;  or  if  visceral  injury  is  inflicted,  it  is  more  likely  that 
only  a  single  perforation  exists,  and  never  does  the  surgeon  meet 
with  such  a  multiplicity  of  lesions  as  have  been  cited  above.  Unless 
the  surgeon  can  ascertain  beforehand,  that  in  a  case  of  penetrating 
wound  of  the  abdomen  an  injury  to  some  portion  of  the  gastro- 
intestinal canal  exists,  the  very  means  which  he  resorts  to  in  making 
an  anatomical  diagnosis  is  often  an  imminent  source  of  danger,  as 
only  too  often  he  may  have  to  examine  every  inch  of  the  gastro- 
intestinal canal  for  this  purpose,  a  procedure  which  is  always 
attended  by  great  risk  to  life.  If  by  such  a  simple  and  harmless 
procedure  as  insufflation  of  hydrogen  gas,  he  can  satisfy  himself 
that  the  gastro- intestinal  canal  is  perforated,  the  course  to  pursue 
becomes  clear— to  open  the  abdomen,  seek  for  the  perforation  until 
he  finds  it,  and  adopt  proper  treatment  for  the  visceral  injury. 

Cases  have  also  happened  in  which  the  operator  opened  the 
abdomen,  sought  for,  found  and  treated  one  or  more  perforations 
and,  on  making  the  autopsy  a  day  or  two  later  found,  to  his  groat 
chagrin  and  sorrow,  a  perforation  which  he  had  overlooked  at  the 


502  EXPERIMENTAL  SURGERY. 

time  of  operation.  It  seems  to  me  that  in  cases  in  which  any  doubt 
exists  as  to  the  integrity  of  the  remaining  portion  of  the  intestinal 
canal,  after  closing  one  or  more  perforations,  it  would  be  advisable 
to  search  for  additional  perforations  by  resorting  again  to  slow  and 
careful  inflation  before  the  abdominal  wound  is  closed.  If  no  other 
perforations  exist  the  gas  will  be  confined  to  the  interior  of  the 
gastro-intestinal  canal,  and  if  the  stomach  or  intestines  at  some  point 
difficult  of  access  are  injured,  the  leakage  of  gas  through  the  perfo- 
rations will  lead  the  surgeon  to  the  wound. 

In  the  practical  application  of  rectal  insufflation  of  hydrogen 
gas,  as  a  means  of  diagnosis  in  penetrating  wounds  of  the  abdomen, 
the  field  of  possible  operation  should  be  carefully  prepared  by  shav- 
ing and  disinfection  before  inflation.  After  thorough  disinfection  of 
the  external  wound  or  wounds,  and  the  field  of  operation,  the  patient 
should  be  placed  thoroughly  under  the  influence  of  an  anaesthetic 
for  the  purpose  of  relaxing  the  abdominal  muscles,  which  greatly 
facilitates  the  inflation. 

In  the  absence  of  a  Wolf's  bottle,  hydrogen  gas  can  be  readily 
generated  in  a  large  wide-mouthed  bottle  into  which  a  small  handful 
of  chips  of  pure  zinc  is  placed.  The  mouth  of  the  bottle  is  closed 
with  a  cork  with  two  perforations,  through  which  two  glass  tubes  are 
inserted,  one  for  the  purpose  of  pouring  in  water  and  sulphuric  acid, 
and  the  other,  which  should  be  bent  nearly  at  right  angles,  for  lead- 
ing away  the  gas.  This  glass  tube  and  a  rubber  balloon  with  a 
capacity  of  sixteen  litres  of  gas  are  connected  by  means  of  a  rubber 
tube.  In  from»five  to  ten  minutes  the  requisite  amount  of  gas  can 
be  generated  and  everything  is  ready  for  the  inflation.  The  rubber 
tube  connecting  the  balloon  with  the  rectal  tip  of  an  ordinary 
syringe  should  be  interrupted  by  a  stop-cock,  so  that  the  escape  of 
gas  can  be  prevented  whenever  inflation  is  temporarily  suspended. 
The  return  of  gas  alonfy  the  sides  of  the  rectal  tip  can  be  readily 
prevented  by  an  assistant  pressing  the  anal  margins  firmly  against  it. 

The  inflation  must  always  be  made  sloivly,  as  long  continued, 
uninterrupted  pressure  accomplishes  most  effectually  lateral  and 
longitudinal  dilatation  of  the  caicum ;  conditions  which  render  the 
ileo-C89cal  valve  incompetent,  and  which  must  be  secured  before 
inflation  of  the  small  intestines  is  possible,  The  entrance  of  gas 
from  the  colon  into  the  ileum  is  always  attended  by  a  diminution  of 


RECTAL  INSUFFLATION  IN  GUNSHOT    WOUNDS.  503 

pressure,  and  its  occurrence  can  invariably  be  recognized  by  a 
gurgling  or  blowing  sound  over  the  ileo-csecal  valve,  sometimes 
sufficiently  loud  to  be  heard  at  some  distance. 

If,  after  inflation,  abdominal  distention  and  tympanites  be  from 
the  very  first  diffuse,  and  liver  dullness  has  disappeared,  it  is  a 
certain  indication  that  they  are  due  to  the  presence  of  gas  in  the 
peritoneal  cavity,  and  not  to  distention  of  the  gastro- intestinal 
canal.  If,  on  the  other  hand,  the  distention  and  tympanites  follow 
the  course  of  the  colon,  and  after  the  entrance  of  the  gas  through 
the  ileo-cjecal  valve,  are  circumscribed  and  limited  to  the  umbilical 
and  hypogastric  regions,  and  gradually  extend  to  the  upper  portion 
of  the  abdomen,  and  the  liver  dullness  is  displaced  upivards,  they  are 
in  all  probability  caused  by  a  gradual  and  successive  inflation  of  the 
intact  bowel  in  an  upward  direction. 

In  some  penetrating  wounds  of  the  abdomen  it  is  difficult,  if 
not  impossible  to  follow  the  course  of  the  bullet  through  the  abdom- 
inal wall  with  a  probe  or  finger,  on  account  of  the  relative  change  of 
position  of  the  different  layers  of  tissues  in  the  track  of  the  bullet, 
obliterating  the  canal;  but  even  in  these  cases  a  moderate  distention 
of  the  peritoneal  cavity  by  an  accumulation  of  gas  outside  of  the 
intestines,  will  force  bubbles  of  gas  through  the  tortuous  canal.  By 
this  sign  the  surgeon  may  know  positively  that  some  portion  of  the 
gastro-intestinal  canal  has  been  perforated;  and  in  order  to  prove 
that  the  bubbles  which  escape  are  part  of  the  hydrogen  gas  which 
has  been  inflated,  he  applies  a  lighted  match  or  taper.  If  it  is 
hydrogen  gas  it  will  ignite  with  a  slight  explosive  report,  and  burn 
with  a  characteristic  blue  flame.  The  burning  of  the  escaping 
hydrogen  gas  on  the  surface  of  the  external  wound  is  a  most  effective 
means  in  securing  for  the  wound  an  aseptic  condition,  and  on  that 
account,  the  escaping  gas  should  be  lighted,  both  for  diagnostic  and 
therapeutic  purposes,  in  all  cases  in  which  rectal  insufflation  of 
hydrogen  gas  reveals  the  presence  of  visceral  injuries  of  the  gastro- 
intestinal canal. 

As  hydrogen  gas  from  its  low  specific  gravity  will  always  occupy 
the  highest  space  in  a  cavity  partially  filled  with  fluids,  it  is  neces- 
sary to  placo  the  external  abdominal  wound  in  sxich  a  position  that 
blood  or  any  other  fluid  that  may  be  present  in  the  abdominal  cavity 
will  not  interfere  with  its   ready  escape.      If  the  wound  is  anterior 


504  EXPERIMENTAL  SURGERY. 

the  patient  must  be  placed  in  the  dorsal  position;  if  lateral,  on  the 
opposite  side,  during  the  inflation.  If  during  inflation,  early  and 
diffuse  tympanites  takes  place,  it  speaks  in  favor  of  perforation  of 
the  colon. 

Should  the  external  wound  prevent  the  escape  of  gas  from  the 
peritoneal  cavity,  by  sliding  of  the  different  layers  of  tissue  of  the 
wound  in  the  abdominal  wall,  or  by  the  presence  of  a  coagulum  in 
the  track  made  by  the  bullet,  it  becomes  necessary  to  secure  a  suffi- 
cient degree  of  patency  of  the  wound  for  the  escape  of  gas,  by  careful 
probing  or  the  removal  of  coagulated  blood.  The  finding  of  perfo- 
rations is  also  greatly  facilitated  by  inflation,  as  the  bowel  below  the 
lowest  perforation  will  always  be  found  at  least  slightly  dilated  by 
gas.  If  this  perforation  is  now  closed  and  additional  perforations 
are  suspected  to  exist,  the  inflation  can  be  repeated,  and  the  bowel 
will  again  become  distended  as  far  as  the  next  perforation,  and  this 
process  can  be  repeated  until  the  entire  intestinal  canal  has  been 
examined.  By  searching  for  leaking  points  in  this  manner,  but  little 
manipulation  of  the  intestines  becomes  necessary,  and  thus  one  of 
the  great  sources  of  danger  in  the  operative  treatment  of  wounds  or 
perforations  of  the  gastro- intestinal  canal  is  avoided. 

The  moderate  distention  of  the  intestines  left  after  treating  the 
visceral  wounds,  never  interfered  with  the  return  of  the  intestines 
into  the  abdominal  cavity  or  the  closure  of  the  external  wound  in 
any  of  the  experiments;  and  the  numerous  observations  made  in 
reference  to  the  disappearance  of  the  gas  by  absorption,  or  escape 
through  the  natural  outlets,  are  conclusive  in  showing  that  the  dis- 
tention due  to  the  presence  of  the  gas  disappears  in  a  remarkably 
short  time.  It  can  therefore  be  safely  stated  that  rectal  insufflation 
of  hydrogen  gas  in  the  diagnosis  and  treatment  of  penetrating 
wounds  of  the  abdomen,  does  not  interfere  with  an  ideal  healing  of 
the  visceral  and  laparotomy  wounds. 

After  a  careful  study  of  the  subject  of  rectal  insufflation  of 
hydrogen  gas  in  its  various  aspects,  I  do  not  hesitate  to  recommend 
its  adoption  in  practice  as  an  infallible  diagnostic  test  in  demon- 
strating the  existence  of  a  wound  of  the  gastro-intestinal  canal  in 
penetrating  wounds  of  the  abdomen,  or  perforations  from  any  other 
cause,  without  resorting  to  an  exploratory  laparotomy. 


CONCLUSIONS.  ■  505 

In  conclusion  I  beg  leave  to  submit  the  following  propositions : 

•1.  The  entire  alimentary  canal  is  permeable  to  rectal  insuffla- 
tion of  air  or  gas. 

2.  Inflation  of  the  entire  alimentary  canal  from  above  down- 
wards through  a  stomach  tube  seldom  succeeds,  and  should  there- 
fore only  be  resorted  to  in  demonstrating  the  presence  of  a  perforation 
or  wound  of  the  stomach,  and  for  locating  other  lesions  in  the  organ 
or  its  immediate  vicinity. 

3.  The  ileo-ctecal  valve  is  rendered  incompetent  and  permea- 
ble, by  rectal  insufflation  of  air  or  gas  under  a  pressure  varying 
from  one -fourth  of  a  pound  to  two  pounds. 

4.  Air  or  gas  can  be  forced  through  the  whole  alimentary 
canal  from  anus  to  mouth,  under  a  pressure  varying  from  one-third 
of  a  pound  to  two  pounds  and  a  half. 

5.  Rectal  insufflation  of  air  or  gas  to  be  both  safe  and  effective 
must  be  done  very  slowly  and  without  interruptions. 

6.  The  safest  and  most  effective  rectal  insufflator  is  a  rubber 
balloon  large  enough  to  hold  sixteen  litres  of  air  or  gas. 

7.  Hydrogen  gas  should  be  preferred  to  atmospheric  air  or 
other  gases  for  purposes  of  inflation  in  all  cases  where  this  pro- 
cedure is  indicated. 

8.  The  resisting  power  of  the  intestinal  wall  is  nearly  the 
same  throughout  the  entire  length  of  the  canal,  and  in  a  normal 
condition  yields  to  diastaltic  force  of  from  eight  to  twelve  pounds  of 
pressure.  When  rupture  takes  place  it  either  occurs  as  a  longitudi- 
nal laceration  of  the  peritoneum  on  the  convex  surface  of  the  bowel, 
or  as  multiple  ruptures  from  within  outwards,  at  the  mesenteric 
attachment.  The  former  result  follows  rapid,  and  the  latter  slow 
inflation. 

9.  Hydrogen  gas  is  devoid  of  toxic  properties,  non-irritating 
when  brought  in  contact  with  living  tissues,  and  rapidly  absorbed 
from  the  connective  tissue  spaces  and  all  of  the  large'  serous  cavities. 

10.  The  escape  of  air  or  gas  through  the  ileo-crecal  valve  from 
below  upwards  is  always  attended  by  a  blowing  or  gurgling  sound, 
heard  most  distinctly  over  the  "ileocecal  region,  and  by  a  sudden 
diminution  of  pressure. 


506  EXPERIMENTAL  SURGERY. 

11.  The  incompetency  of  the  ileo-csecal  valve  is  caused  by  a 
lateral  and  longitudinal  distention  of  the  caecum,  which  mechanically 
separates  the  margins  of  the  valve. 

12.  In  gunshot  or  punctured  wounds  of  the  gastro- intestinal 
canal,  insufflation  of  hydrogen  gas  enables  the  surgeon  to  demon- 
strate positively  the  existence  of  the  visceral  injury,  without  incur- 
ring the  risks  and  medico- legal  responsibilities  incident  to  an 
exploratory  laparotomy. 


INDEX. 


A  Page. 

BDOMEN.  Diagnosis    of   gunshot   wound   of,  by    rectal   insufflation 

of  hydrogen  gas.      Experiments 497 

Penetrating    wound     of,     with   protrusion   of     pancreas. 

Cases 338 

Abscess  of  pancreas.     Cases 357 

Pathology  of 364 

Prognosis 367 

Symptoms  and  diagnosis 366 

Treatment 366 

Acute  pancreatitis.     Cases   368 

Adhesion   experiments 457 

Adventitia  of  blood-vessels 118 

Air.     Aspiration  of,  from  the  heart  in  treatment  of  air-embolism 282 

into  longitudinal  sinus.     Experiments 216 

Practical  suggestions 223 

superior  longitudinal  sinus 214 

Air-Embolism.    Aseptic   tampon  in  treatment   of 277 

Aspiration  of  air  from  the  heart  in  treatment  of 282 

right  ventricle  for.     Experiments 262 

Cardiac  stimulation  in  treatment  of 279 

Catheterization  and  aspiration  of  right  auricle  for  venous. 

Experiments 268 

Clinical  study  of . .   236 

Compression  in  treatment  of 274 

Experimental  and  clinical  study  of 197 

Experiments  on  arterial 257 

venous 252 

History  of 204 

Ligature  in  treatment  of 277 

Operative  treatment  of 278 

Position  in  treatment  of 272 

Prevention  of  further  ingress  of  air  in  treatment  of 278 

Prophylactic  treatment  of 272 

Summary 286 

Venesection  in  treatment  of ■ 280 

Air.     Experiments  on  direct  intra-cardiac  insufflation  of 261 

Immediate  cause  of  death  after  intravenous  insufflation  of 227 

507 


508  INDEX. 

Page. 

Air.     Intra-arterial  insufflation  of 233 

Intravenous  production  of 207 

Prevention  of  further  ingress  of,  in  treatment  of  air-embolism 278 

Rectal  insufflation  of.     Experiments 480 

Alimentary  canal.     Pressure  necessary  to  force  hydrogen  gas  through  en- 
tire— by  rectal  inflation.     Experiments 487 

Alteration  of  motion  in  fracture  of  neck  of  femur 51 

Anatomy,  comparative,  of  pancreas 289 

of  neck  of  femur 10 

Arterial  air-embolism.    Experiments 257 

Arteries.     Double  ligation  of.     Experiments 173 

temporary  ligation  of.     Experiments 178 

Artery  and  vein.     Ligation  of.     Experiments 184 

Artificial  intestinal  obstruction 404 

Aseptic  ligature 129 

tampon  in  treatment  of  air-embolism 277 

Aspiration.     Catheterization  and — of  right  auricle  for  venous  air-embol- 
ism.    Experiments 268 

of  air  from  the  heart  in  treatment  of  air-embolism 282 

into  longitudinal  sinus.     Experiments 216 

Practical  suggestions 223 

superior  longitudinal  sinus 214 

of  right  ventricle  for  air-embolism.     Experiments 262 

Auricle.     Catheterization  and  aspiration  of  right — for  venous  air-embol- 
ism.    Experiments 268 

Author's  Modification  of  Jobert's  Suture 425 

Illustration 471 

JjLOOD-VESSELS.     Adventitia  of 118 

Cicatrization  of,  after  ligature 101 

Experiments. .   153,  172 

Histology  of 113 

Intima  of 114 

Media  of 116 

Primary  union  in,  after  ligature 170 

Remarks    on    experiments    on    cicatrization  of, 

after  ligature 184 

Bone-pegs.     Fixation  by,  in  fracture  of  neck  of  femur 95 

plates  for  intestinal  anastomosis.     Preparation  of 437 

transplantation  after  fracture  of  neck  of  femur 62 

Bony  union  after  fracture  of  neck  of  femur 1 

Specimens 68 

impacted  intra-capsular  fracture  of  neck  of  femur 7,  83 

\j  ALLUS,  production  of,  after  fracture  of  neck  of  femur 58 

Cancer  of  pancreas.     Symptoms  and  diagnosis 387 


INDEX.  509 

Page. 

Cancer  of  pancreas.     Treatment 388 

Carcinoma  of  pancreas 385 

Cardiac  stimulation  in  treatment  of  air-embolism 279 

Cases.    Bony  union  after  impacted  intra-capsular  fracture  of  neck  of  femur.  7 

Hypertrophy  of  pancreas 383 

Abscess  of  pancreas 357 

Acute  pancreatitis 348 

Chronic  interstitial  pancreatitis 351 

Contusion  of  pancreas 338 

Cysts  of  pancreas 379 

Diffuse  haemorrhage  of  pancreas 373 

Embolism 238 

Gangrene  of  pancreas 355 

Gunshot  wounds  of  pancreas 341 

Hemorrhagic  cysts  of  pancreas 371 

Penetrating  wound  of  abdomen  with  protrusion  of  pancreas 338 

Sarcoma  of  pancreas 384 

Sclerosis  of  pancreas 351 

Tuberculosis  of  pancreas 390 

Catheterization  and  aspiration  of  right  auricle  for  venous  air-embolism. 

Experiments 268 

Causes,  exciting,  of  fracture  of  neck  of  femur 37 

predisposing,  of  fracture  of  neck  of  femur 36 

Change  of  position  of  trochanter  major  in  fracture  of  neck  of  femur. ...  51 

Chemical  irritation  of  serous  surfaces.     Experiments 461 

Chronic  interstitial  pancreatitis.     Cases 351 

Cicatrix,  extra-vascular,  after  ligature 188 

Formation  of,  after  ligature 138 

by  adhesive  inflammation  after  ligature 139 

from  connective  tissue  after  ligature 165 

endothelia  after  ligature 150 

fibrin  after  ligature 141 

immigration  corpuscles  after  ligature 147 

red  blood-corpuscles  after  ligature 147 

white  blood-corpuscles  after  ligature 143 

Intra-vascular,  after  ligature 188 

Microscopical  appearances  of....  191 

Cicatrization  in  blood-vessels  after  ligature 101 

Experiments 153,  172 

Remarks  on  experiments..  184 

Circular  constriction.     Intestinal  stenosis  by.     Experiments 405 

enterorrhaphy.     Experiments 424 

Nothnagel's  test.      Experiments 429 

Transplantation  of  omental  flap.    Experiments.  430 

Circulation,  venous.     Effect  of  heart  and  respiration  on 208 

Classification  of  fractures  of  neck  of  femur 20 


510  INDEX. 

Page. 

Clinical  study  of  air-embolism 236 

Coaptation.     Reduction  and — in  fracture  of  neck  of  femur 92 

Colo-rectostomy.     Experiments 456 

Colon,  excision  of.     Experiments 419 

Comminution  of  pancreas.     Experiments 304 

Comparative  anatomy  of  pancreas 289 

Complete  extirpation  of  pancreas.     Experiments 306 

section  of  pancreas.     Experiments 300 

Compression  in  treatment  of  air-embolism 274 

Conclusions.     Intestinal  obstruction 466 

Pancreas •  •   397 

Connective  tissue.     Formation  of  cicatrix  from,  after  ligature 165 

Contusion  of  pancreas.     Cases 338 

Corpuscles.     Formation  of  cicatrix  from  immigration,  after  ligature 147 

red  blood-,  after  ligature 147 

white  blood-,  after  ligature 143 

Cyst,  hsemorrhagic  of  pancreas.     Cases 371 

Cysts  of  the  pancreas.     Cases 379 


D 


E ATH     Immediate  cause  of,  after  intravenous  insufflation  of  air 227 

in  rapidly  fatal  embolism 198 

Deformity  in  fracture  of  neck  of  femur 47 

Development  of  pancreas 291 

Diagnosis  of  abscess  of  pancreas 366 

cancer  of  pancreas 387 

haemorrhage  of  pancreas 377 

fracture  of  neck  of  femur 52 

pancreatic  lithiasis 395 

penetrating  gunshot  wounds  of  abdomen  by  rectal  insufflation 

of  hydrogen  gas.     Experiments 497 

Diastaltic  force.     Resistance  of  gastro-intestinal  canal  to.     Experiments.   489 

Diffuse  haemorrhage  of  pancreas.    Cases 373 

Direct  intra-cardiac  insufflation  of  air.     Experiments 261 

ligature 121 

Distention  of  gastro-intestinal  canal  by  rectal  insufflation  of  hydrogen 

gas.     Experiments 491 

Double  ligation  of  arteries.     Experiments 173 

veins.     Experiments 180 

ligature 122 

temporary  ligation  of  arteries.     Experiments 178 

veins.     Experiments 182 

IjFFECT  of  heart  and  respiration  on  venous  circulation 208 

of  suppuration  after  ligature 184 

Embolism,  air.     See  air-embolism 

Cases  of 238 


INDEX.  511 

Page. 

Embolism.    Immediate  cause  of  death  in  rapidly  fatal 198 

Endothelia.     Formation  of  cicatrix  from,  after  ligature 150 

Enterectomy.    Experiments 416 

Intestinal  stenosis  by  partial.     Experiments 404 

Enterorrhaphy,  circular.      Experiments .- . .   424 

Nothnagel's  test.     Experiments 429 

Transplantation  of  omental  flap.  Experiments.  430 

Eversion  in  fracture  of  neck  of  femur 47 

Excision  of  colon.     Experiments 419 

Exciting  causes  of  fracture  of  neck  of  femur 37 

Experimental  and  clinical  study  of  air-embolism 197 

contribution  to  intestinal  surgery 399 

Experiments.     Adhesions 457 

Arterial  air-embolism 257 

Aspiration  of  air  into  longitudinal  sinus 216 

Aspiration  of  right  ventricle  for  air-embolism 262 

Catheterization  and  aspiration  of  right  auricle  for  venous 

air-embolism 268 

Chemical  irritation  of  serous  surfaces 461 

Cicatrization  of  blood-vessels  after  ligature 153,  1 72 

Remarks... .   184 

Circular  enterorrhaphy 424 

Colo-rectostomy 456 

Comminution  of  pancreas    304 

Complete  extirpation  of  pancreas 306 

Complete  section  of  pancreas 300 

Diagnosis    of    gunshot   wounds   of    abdomen   by   rectal 

insufflation  of  hydrogen  gas 497 

Direct  intra-cardiac  insufflation  of  air 261 

Distention  of  gastro-intestinal  canal  by  rectal  insufflation 

of  hydrogen   gas 491 

Double  ligation  of  arteries 173 

veins 180 

temporary  ligation  of  arteries 178 

veins 182 

Enterectomy 416 

Excision  of  colon 419 

External  pancreatic  fistula 328 

Fracture  of  neck  of  femur 1 

Gastroenterostomy 438 

Intestinal  anastomosis 435 

Obstruction  from  flexion 407 

invagination 410 

stenosis 404 

volvulus 409 

Remarks  on 402 


512  INDEX. 

Page. 

Experiments.     Intestinal  stenosis  by  circular  constriction 405 

partial  enterectomy 404 

Ileo-colostomy 447 

Ileo-rectostomy 455 

Inflation  through  stomach  tube 483 

Innocuity  of  hydrogen  gas  in  contact  with  living  tissues .  496 

Internal  pancreatic  fistula 332 

Jejuno-ileostomy 441 

Laceration  of  pancreas 303 

Ligation  of  artery  and  vein 184 

pancreatic  duct 314 

Nothnagel's  test.     Circular  enterorrhaphy 429 

Omental  grafting 463 

Pancreas 299 

Partial  extirpation  of  pancreas 311 

Permanent  ligature 128 

Permeability  of  ileo-caecal  valve 415 

Physiological  exclusion  of  intestines 421 

Pressure  necessary  to  force  hydrogen  gas  through  entire 

alimentary  canal  by  rectal  inflation 487 

Pressure  necessary  to  render  ileo-csecal  valve  incompetent.  485 

Rectal  insufflation  of  air 480 

Resistance  of  gastro-intestinal  canal  to  diastaltic  force. .  489 

ileo-cascal  valve  to  injections  of  fluid 479 

Transplantation  of  omental  flap.   Circular  enterorrhaphy.  430 

Traumatic  irritation  of  serous  surfaces 458 

Venous  air-embolism 252 

External  pancreatic  fistula.     Experiments 328 

Extirpation,  complete,  of  pancreas.     Experiments 306 

partial,  of  pancreas.     Experiments 311 

Extra-vascular  cicatrix  after  ligature 188 

jl  ASCIA  LATA,  relaxation  of,  in  fracture  of  neck  of  femur 52 

Femur.     Anatomy  of  neck  of 10 

Alteration  of  motion  in  fracture  of  neck  of 51 

Bone  transplantation  after  fracture  of  neck  of 62 

Change  of  position  of  trochanter  major  in  fracture  of  neck  of.  51 

Classification  of  fractures  of  neck  of 20 

Diagnosis  of  fracture  of  neck  of 52 

Eversion  in  fracture  of  neck  of 47 

Exciting  causes  of  fracture  of  neck  of 37 

Fixation  by  bone-pegs  in  fracture  of  neck  of 95 

in  fracture  of  neck  of 92 

Fracture  of  neck  of , 1 

Impacted  fracture  of  neck  of 27 

Incomplete  fracture  of  neck  of 25 


INDEX.  5 1 3 

Page. 

Femur.     Lateral  pressure  in  fracture  of  neck  of 93 

Loss  or  impairment  of  function  in  fracture  of  neck  of 46 

Objective  symptoms  of  fracture  of  neck  of 46 

Pain  in  fracture  of  neck  of 45 

Predisposing  causes  of  fracture  of  neck  of 36 

Production  of  callus  after  fracture  of  neck  of 58 

Reduction  and  coaptation  in  fracture  of  neck  of 92 

Relative  number  of  intra-  and  extra-capsular  fractures  of   neck 

of 22 

Relaxation  of  fascia  lata  in  fracture  of  neck  of 52 

Shortening  in  fracture  of  neck  of 49 

Specimens  of  bony  union  after  fracture  of   neck  of 68 

Subjective  symptoms  of  fracture  of  neck  of 45 

Suggillation  in  fracture  of  neck  of 47 

Swelling  and  deformity  in  fracture  of  neck  of 47 

Symptoms  of  fracture  of  neck  of 44 

Treatment  of  fracture  of  neck  of 89 

Fibrin.     Formation  of  cicatrix   from,  after  ligature 141 

Fistula.    External  pancreatic.      Experiments 328 

Internal  pancreatic.      Experiments 332 

Fixation  by  bone-pegs  in  fracture  of  neck  of  femur 95 

in  fracture  of  neck  of  femur 92 

Flexion.     Intestinal  obstruction  from.      Experiments 407 

Formation  of  cicatrix  after  ligature 138 

by  adhesive  inflammation  after  ligature 139 

from  connective  tissue  after  ligature 165 

endothelia  after  ligature 150 

fibrin  after  ligature 141 

immigration  corpuscles  after  ligature 147 

red  blood-corpuscles  after  ligature 147 

white  blood-corpuscles  after  ligature 143 

Fracture.     Bony  union  after  intra-capsular 83 

Non-union  after  intra-capsular 80 

of  neck  of  femur.     Alteration  of  motion  in 51 

Bone  transplantation  after 62 

Change  of  position  of  trochanter  major  in  51 

Diagnosis  of 52 

Eversion  in 47 

Exciting  causes 37 

Fixation  by  bone-pegs  in 95 

in 92 

Impacted 27 

Incomplete 25 

Lateral  pressure  in 93 

Loss  or  impairment  of  function  in 46 

Objective  symptoms  of 46 


514  INDEX. 

Page. 
Fracture  of  neck  of   femur.     Pain  in 45 

Predisposing  causes  of 36 

Production  of  callus  after 58 

Reduction  and  coaptation  in 92 

Relaxation  of  fascia  lata  in 52 

Shortening  in 49 

Specimens  of  bony  union  after 68 

Subjective  symptoms  of 45 

Suggillation  in 47 

Swelling  and  deformity  in 47 

Symptoms  of , . . .  44 

Treatment  of 89 

Fractures  of  neck  of  femur.     Classification 20 

Relative  number  of  intra-  and  extracap- 
sular    22 

Function.     Loss  or  impairment  of,  in  fracture  of  neck  of  femur 46 

(jTANGRENE  of  pancreas.     Cases 355 

Treatment 357 

Gastro-enterostomy.     Experiments 438 

Gastro-intestinal  canal.     Diagnosis  of  wounds  of,  by  rectal  insufflation  of 

hydrogen  gas 473 

Distention  of,  by  rectal  insufflation  of    hydro- 
gen gas.     Experiments 491 

Resistance  of,  to  diastaltic  force.     Experiments.  489 

General  remarks  on  experiments  on  intestinal  obstruction 402 

Grafts.     Omental.     Experiments 463 

Gunshot  wounds  of  abdomen.     Diagnosis  of,  by  rectal  insufflation  of  hy- 
drogen gas.     Experiments 497 

of  pancreas.     Cases 341 

rl^MORRHAGE  of  pancreas 370 

Diffuse.     Cases 373 

Symptoms  and  diagnosis  of 377 

Treatment 378 

Haemorrhagic  cyst  of  pancreas.     Cases 371 

Heart  and  respiration.     Effect  of,  on  venous  circulation 208 

Heart.     Aspiration  of  air  from,  in  treatment  of  air-embolism 282 

Histology  of  blood-vessels 113 

History  of  air-embolism 204 

the  ligature 103 

Hydrogen  gas.     Diagnosis  of  wounds  of  gastro-intestinal  canal  by  rectal 

insufflation  of 473 

Diagnosis  of  gunshot  wounds  of  abdomen  by  rectal  in- 
sufflation of.     Experiments 497 


INDEX.  515 

Page. 
Hydrogen  gas.     Distention  of   gastro-intestinal  canal  by  rectal  insuffla- 
tion of.     Experiments 491 

Innocuity  of,  in  contact  with  living   tissues.      Experi- 
ments      49g 

Pressure  necessary  to    force,  through  entire  alimentary 

canal  by  rectal  inflation.     Experiments 487 

Hypertrophy  of  pancreas.     Case 333 

lLEO-CaECAL  valve.     Permeability  of 476 

Experiments 415 

Pressure  necessary  to  render  incompetent.     Ex- 
periments    485 

Resistance"  of,    to  injections  of    fluid.      Experi- 
ments    479 

Ileo-colostomy.     Experiments 447 

Ileo-rectostomy.     Experiments 455 

Illustration,  author's  modification  of  Jobert's  suture 471 

intestinal  anastomosis 471 

Immediate  cause  of  death  after  intravenous  insufflation  of  air 227 

in  rapidly  fatal  air-embolism 198 

ligature 121 

Immigration  capsules.     Formation  of  cicatrix  from,  after  ligature 147 

Impacted  fracture  of  neck  of  femur 27 

intra-capsular  fracture  of  neck  of  femur.      Bony  union  after.. .  7 

Impairment  of  function  in  fracture  of  neck  of  femur 40 

Incomplete  fracture  of  neck  of  femur 25 

Inflammation.     Formation  of  cicatrix  after  ligature  by 139 

Inflation  through  stomach  tube.     Experiments 483 

Innocuity  of  hydrogen  gas  in  contact  with  living  tissues.     Experiments..  496 

Insufflation,  intra-arterial,  of  air 233 

of  air.     Direct  intra-cardiac.     Experiments 261 

Rectal.      Experiments 480 

Immediate  cause  of  death  after  intravenous 227 

of  hydrogen  gas  in  diagnosis  of  wounds  of  gastro-intestinal 

canal 473 

Intermediate  ligature 120 

Internal  pancreatic  fistula.     Experiments 332 

Interstitial  pancreatitis,  chronic.     Cases 851 

Intestinal  anastomosis.     Experiments 435 

Illustration 471 

Preparation  of  bone  plates  for 437 

obstruction.      Artificial 404 

Conclusions 166 

from  flexion.     Experiments 407 

invagination.     Experiments 410 

-t>'iiosi~.       Kx|»eriments 404 


516  INDEX. 

Page. 

Intestinal  obstruction  from  volvulus.     Experiments 409 

General  remarks  on  experiments 402 

Treatment  of 399 

stenosis  by  cireular  constriction.     Experiments 405 

partial  enterectomy.      Experiments 404 

surgery.     Experimental  contribution  to 399 

Intestines.     Physiological  exclusion  of.     Experiments   421 

Intima  of  blood-vessels 114 

Intra-arterial  insufflation  of  air 2J53 

and  extra-capsular  fractures  of  neck  of  femur.     Relative  number  of     22 

capsular  fracture.      Bony  union  after 83 

Non-union  after 80 

of  neck  of  femur.     Bony  union  after 1 

cardiac  insufflation  of  air.     Direct.     Experiments 261 

vascular  cicatrix  after  ligature 188 

Microscopical  appearances  of 191 

Intravenous  insufflation  of  air.     Immediate  cause  of  death  after 227 

production  of  air 207 

Invagination.     Intestinal  obstruction  from.      Experiments 410 

Irritation,  chemical,  of  serous  surfaces.    Experiments 461 

Traumatic,  of  serous  surfaces.      Experiments 458 

J  EJUNO-ILEOSTOMY.     Experiments 441 

Jobert's  suture.     Author's  modification  of 425 

Illustration 471 

J_j ACERATION  of  pancreas.     Experiments 303 

Lateral  pressure  in  fracture  of  neck  of  femur 93 

Ligation,  double,  of  arteries.    Experiments 172 

of  veins.     Experiments 180 

temporary,  of  arteries.     Experiments 178 

veins.     Experiments 182 

of  artery  and  vein.     Experiments 184 

of  pancreatic  duct.     Experiments 314 

Ligature.     Aseptic 129 

Cicatrization  of  blood-vessels  after 101 

Experiments 153,  172 

Double 122 

Effect  of  suppuration  after 184 

en  masse 120 

Extra-vascular  cicatrix  after 188 

Formation  of  cicatrix  after 138 

by  adhesive  inflammation  after 139 

from  connective-tissue  after 165 

endothelia  after   150 


INDEX.  517 

Page. 

Ligature.     Formation  of  cicatrix  from  fibrin  after 141 

immigration  corpuscles  after ....    147 

red  blood-corpuscles  after 147 

white  blood-corpuscles  after 143 

History  of  the 103 

Immediate  or  direct 121 

Intermediate 120 

Intra-vascular  cicatrix  after 188 

in  treatment  of  air-embolism  . . . . 277 

Microscopical  appearances  of  intra-vascular  cicatrix  after...    191 

Momentary 123 

Permanent 126 

Experiments 128 

Practical  suggestions  on 193 

Primary  union  in  blood-vessels  after 170 

Remarks  on  experiments  on  cicatrization  of  blood-vessels  after  184 

Temporary 123,  190 

Thrombosis  after 135 

Thrombus  after 185 

Lipomatosis  of  pancreas 391 

Lithiasis,  pancreatic 393 

Symptoms  and  diagnosis 395 

Treatment 396 

Living  tissues.    Innocuity  of  hydrogen  gas  in  contact  with.  Experiments.  496 

Longitudinal  sinus.     Aspiration  of  air  into.     Experiments 216 

Practical  suggestions  on  aspiration  of  air  into 223 

Superior.      Aspiration  of  air  into 214 

Loss  of  function  in  fracture  of  neck  of  femur 46 

1V1 EDIA  of  blood-vessels H<> 

Meyer's  traction  curves '•  •  •  •  12 

Microscopical  appearances  of  intra-vascular  cicatrix  after  ligature 191 

Momentary    ligature 123 


N 


ECK  of  femur.     Alteration  of  motion  in  fracture  of  neck  of 51 

Anatomy  of 10 

Bone  transplantation  after  fracture  of 62 

Change  of  position  of  trochanter  major  in  fracture  of  51 

Classification  of  fractures  of 20 

Diagnosis  of  fracture  of 52 

Eversion  in  fracture  of 47 

Exciting  caust-s  of  fraotnre  of 37 

Fixation  by  hone-pegs  in  fracture  of '.»."» 

in  fracture  of 92 

Impacted  fraotnre  of 27 


518  INDEX. 

Page. 

Neck   of    femur.       Incomplete  fracture  of 25 

Lateral  pressure  in  fracture  of ■ 93 

Loss  or  impairment  of  function  in  fracture  of 46 

Objective  symptoms  of  fracture  of 46 

Pain  in  fracture  of 45 

Predisposing  causes  of  fracture  of 36 

Production  of  callus  after  fracture  of 58 

Reduction  and  coaptation  in  fracture  of 92 

Relaxation  of  fascia  lata  in  fracture  of 52 

Shortening  in  fracture  of , 49 

Specimens  of  bony  union  after  fracture  of 68 

Subjective  symptoms  of  fracture  of 45 

Suggillation  in  fracture  of 47 

Swelling  and  deformity  in  fracture  of 47 

Symptoms  of  fracture  of 44 

Treatment  of  fracture  of 89 

Non-union  after  intra-capsular  fracture 80 

Nothnagel's  test.     Circular  enterorrhaphy.     Experiments 429 

Nunber  of  intra-  and  extra-capsular  fractures  of  neck  of  femur 22 


0. 


/BJECTIVE  symptoms  of  fracture  of  neck  of  femur 46 

Omental  flap.     Transplantation  of.  Circular  enterorrhaphy.  Experiments.  430 

grafting.     Experiments 463 

Operative  treatment  of  air-embolism 278 

Organization  of  thrombus 137 

Osteo-porosis.     Senile 38 


R 


AIN  in  fracture  of  neck  of   femur 45 

Pancreas.     Abscess  of.     Cases 357 

^                              Pathology 364 

Prognosis 367 

Symptoms  and  diagnosis 366 

Treatment 368 

Cancer  of.     Symptoms  and  diagnosis 387 

Treatment 388 

Carcinoma  of 385 

Comminution  of.     Experiments 304 

Comparative  anatomy  of 289 

Complete  extirpation  of.     Experiments 306 

section  of.     Experiments 300 

Conclusions 397 

Contusion  of.     Cases 338 

Cysts  of.     Cases 379 

Development  of 291 

Diffuse  haemorrhage  of.     Cases 373 


INDEX.  519 

Page. 

Pancreas.     Experiments 299 

Gangrene  of.     Cases 355 

Treatment 357 

Gunshot  wounds  of.      Cases 341 

Hemorrhage   of 370 

Symptoms  and  diagnosis 377 

Treatment 378 

Hemorrhagic  cysts  of.     Cases 371 

Hypertrophy  of.     Case 383 

Laceration  of.     Experiments 303 

Lipomatosis  of 391 

Partial  extirpation  of.     Experiments 311 

Penetrating  wound  of  abdomen,  with  protrusion  of.    Cases...   338 

Physiology  of 295 

Sarcoma  of.     Cases 384 

Sclerosis  of.     Cases 351 

Treatment 352 

Surgery  of 289 

Tuberculosis  of.      Cases 390 

Tumors   of 383 

Wounds  of 338 

Pancreatic  duct.     Ligation  of.     Experiments 314 

fistula,  external.     Experiments 328 

internal.     Experiments 332 

lithiasis 393 

Symptoms  and  diagnosis 395 

Treatment 396 

Pancreatitis.     Acute.     Cases 348 

Chronic  interstitial.     Cases 357 

Partial  enterectomy.     Intestinal  stenosis  by.     Experiments 404 

extirpation  of  pancreas.     Experiments 311 

Pathology  of  abscess  of  pancreas 364 

Penetrating  wound  of  abdomen  with  protrusion  of  pancreas.     Cases 338 

Permanent  ligature 126 

Experiments 128 

Permeability  of  ileo-caecal  valve 476 

Experiments 415 

Physiological  exclusion  of  intestines.     Experiments 421 

Physiology  of  pancreas -'it.r> 

Position  in  treatment  of  air-embolism 272 

Practical  suggestions  on  aspiration  of  ail  into  longitudinal  sinus    22.3 

ligature 193 

Predisposing  causes  of  fracture  of  neck  of  femur 36 

Preparation  of  bone  plates  for  intestinal  anastomosis 437 

Pressure,  lateral,  in  fracture  of  neck  ot  femur 98 


520  INDEX. 

Page. 

Pressure,  necessary  to  force  hydrogen  gas  through  entire  alimentary  canal 

by  rectal  inflation.     Experiments 487 

necessary  to  render  ileo-csecal  valve  incompetent.    Experiments.  485 

Prevention  of  further  ingress  of  air  in  treatment  of  air-embolism 278 

Primary  union  in  blood-vessels  after  ligature 170 

Production  of  callus  after  fracture  of  neck  of  femur 58 

Prognosis  of  abscess  of  pancreas 367 

Prophylactic  treatment  of  air-embolism 272 

Protrusion  of  pancreas.     Penetrating  wound  of  abdomen  with.     Cases. .  .  338 


R 


^ECTAL  inflation.     Pressure  necessary  to  force  hydrogen  gas  through 

entire  alimentary  canal  by.     Experiments 487 

insufflation  of   air.     Experiments 480 

hydrogen  gas.     Distention  of  gastro-intestinal 

canal  by.     Experiments.  491 
in  diagnosis  of  gunshot  wounds 
of   abdomen.       Experi- 
ments   497 

in  diagnosis  of  injury  of  gastro- 
intestinal canal  in  pene- 
trating wounds  of  abdo- 
men    473 

Red  blood-corpuscles.     Formation  of  cicatrix  from,  after  ligature 147 

Reduction  and  coaptation  in  fracture  of  neck  of  femur 92 

Relative  number  of  intra- and  extra-capsular  fractures  of  neck  of  femur..  22 

Relaxation  of  fascia  lata  in  fracture  of  neck  of  femur 52 

Remarks  on  experiments.     Cicatrization  of  blood-vessels  after  ligature.  .  184 

Resistance  of  gastro-intestinal  canal  to  diastaltic  force.     Experiments.  .  .  489 

of  ileo-csecal  valve  to  injections  of  fluid.     Experiments 479 

Respiration.     Effect  of  heart  and,  on  venous  circulation 208 

Right     auricle.      Catheterization    and    aspiration    of,    for    venous    air- 
embolism.     Experiments 268 

ventricle.     Aspiration  of,  for  air-embolism.     Experiments 262 

O ARCOMA  of  pancreas.     Cases 384 

Scarpa's  aplatissement 121 

Schenkelsporn 15 

Sclerosis  of  pancreas.     Cases 351 

Treatment 352 

Section,  complete,  of  pancreas.     Experiments 300 

Senile  osteo-porosis 38 

Serous  surfaces.      Chemical  irritation  of.     Experiments 461 

Traumatic  irritation  of.     Experiments 458 

Shortening  in  fracture  of  neck  of  femur 49 


INDEX.  521 

Page. 

Sinus.     Aspiration  of  air  into  longitudinal.     Experiments 216 

Practical  suggestions 223 

superior  longitudinal 214 

Specimens  of  bony  union  after  fracture  of  neck  of  femur 68 

Stenosis,  intestinal,  by  circular  constriction.     Experiments 405 

partial  enterectomy.     Experiments 404 

obstruction  from.    Experiments 404 

Stimulation,  cardiac,  in  treatment  of  air-embolism 279 

Stomach  tube.     Inflation  through.     Experiments , 483 

Suggestions  on  ligature 193 

Suggillation  in  fracture  of  neck  of  femur 47 

Summary.     Air-embolism 286 

Superior  longitudinal  sinus.     Aspiration  of  air  into 214 

Suppuration  after  ligature.     Effect  of 184 

Surgery.     Intestinal.     Experimental  contribution  to 399 

of  the  pancreas 289 

Swelling  in  fracture  of  neck  of  femur •. .  .     47 

Symptoms,  objective,  of  fracture  of  neck  of  femur 46 

of  abscess  of  pancreas 366 

of  cancer  of  pancreas 387 

of  fracture  of  neck  of  femur 44 

of  haemorrhage  of  pancreas 377 

of  pancreatic  lithiasis 395 

Subjective,  of  fracture  of  neck  of  femur 45 

1  EMPORARY  ligation,  double,  of  arteries.     Experiments 178 

Veins.     Experiments 182 

Ligature 123,  190 

Thrombosis  after  ligature 1 35 

Thrombus  after  ligature 185 

Organization  of 137 

Traction  curves.     Meyer's 12 

Transplantation  of  bone  in  fracture  of  neck  of  femur 62 

omental  Hap.     Circular  enterorrhaphy.    Experiments  430 

Traumatic  irritation  of  serous  surfaces.     Experiments 458 

Treatment  of  abscess  of  pancreas 368 

air-embolism.     Aseptic  tampon 277 

Aspiration  of  air  from  the  heart 282 

Cardiac  stimulation 279 

Compression 2  7 1 

Ligature 277 

Operative 278 

Position -'72 

Prevention  of  further  ingress  of  air 278 

Prophylactic '-'7-_' 

Venesect  ion 280 


522  INDEX. 

Page. 
Treatment  of  cancer  of  pancreas 388 

fracture  of  neck  of  femur 89 

gangrene  of  pancreas 357 

haemorrhage  of  pancreas 378 

intestinal  obstruction 399 

pancreatic  lithiasis 396 

sclerosis  of  pancreas 352 

Trochanter  major.     Change  of  position  of,  in  fracture  of  neck  of  femur..  51 

Tuberculosis  of  pancreas.     Cases 390 

Tumors  of  pancreas 383 

U  NION,  primary,  in  blood-vessels  after  ligature 170 


V, 


ARIETIES  of  ligature 187 

Vein.     Ligation  of  artery  and.     Experiments 184 

Veins.     Double  ligation  of.      Experiments 180 

temporary  ligation  of.     Experiments 182 

Venesection  in  treatment  of  air-embolism 280 

Venous  air-embolism.      Catheterization  and  aspiration  of  right  auricle 

for.     Experiments 268 

Experiments 252 

circulation.     Effect  of  heart  and  respiration  on 208 

Ventricle.     Aspiration  of  right,  for  air-embolism.     Experiments 262 

Volvulus.     Intestinal  obstruction  from.     Experiments 409 


w. 


HITE  blood-corpuscles.     Formation  of  cicatrix  from,  after  ligature.  143 

Wounds,  gunshot,  of  pancreas.     Cases 341 

of  gastro-intestinal  canal.     Diagnosis  of,  by  rectal  insufflation  of 

hydrogen  gas 473 

pancreas 338 


IMPORTANT  NEW  BOOK. 


INTESTINAL  SURGERY 

By  N.  SENN,  Ph.  D.,  M.D. 


The  surgery  of  the  intestines  of  to-day  is  entirely  different  from 
that  of  ten  years  ago.  A  number  of  conditions  formerly  left  to 
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An  amount  of  experimental  work  hitherto  unknown,  a  thorough 
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The  surgery  of  intestinal  obstruction  has  always  been  a  dark 
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Complete  in  Oim-  HuikIhoiiic  Octavo  Volume.  Cloth,  with  Illustrations. 

Price  S2.50. 


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NOW  READY! 

Indigestion  and  Biliousness. 

BY 

J.   MILNER  FOTHERGILL,  M.D., 

Member  of  the  Royal  College  of  Physicians  of  London;     Senior  Assistant  Physician  to  th< 

City  of  London  Hospital  for  Diseases  of  the  Chest  (Victoria  Park);    late  Assistant 

Physician  to  the  West  London  Hospital;    Associate  Fellow  of  the 

College  of  Physicians  of  Philadelphia. 


"Dr.  Fothergill's  writings  always  command  attention;  they  are  sprightly 
and  full  of  instructive  facts,  drawn  mostly  from  his  own  large  experience. 
This  volume  is  written  from  a  physiological  standpoint,  and  begins  with  an 
account  of  natural  digestion,  by  way  of  introduction  or  antithesis  to  the 
main  topic  of  the  book.  As  the  liver  is  the  great  storehouse  of  supplies  for 
the  use  of  the  system,  four  chapters  are  devoted  to  its  functions  and  their 
disturbances.  In  referring  to  the  influence  of  mental  strain  and  worry,  Dr. 
Fothergill  says:  'Talking  one  day  with  Mr.  Van  Abbott,  whose  biscuits  for 
diabetics  have  such  a  well-deserved  renown,  I  asked  him,  "  Who  are  your 
diabetics  mostly?  "  The  reply  was  very  significant.  "  Business  men,  com- 
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abound  in  practical  hints  of  the  greatest  possible  utility  to  the  practicing 
physician.  Altogether,  the  work  is  a  remarkably  comprehensive  study  of  a 
subject  which  is  too  little  understood  by  the  majority  of  medical  men." 

— Neiv  York  Medical  Record. 


One  Volume,  12mo.,  Cloth,  $2.25. 

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NOW  READY! 

&   INSOliNIii   & 

AND fc 

OTHER    DISORDERS    OF    SLEEP. 

BY  — 

HKMIV  M.  LYJIA\.  A.M..  M.D. 

Professor  of  Physiology  and  Diseases  of  the  Nerves  in  Rush  Medical  College. 

Prof,  of  Theory  and  Practice  of  Medicine  in  The  Woman's  Medical  College. 
Physician  to  Presbyterian  Hospital  of  Chicago. 


CONTENTS: 


I.— Nature  and  Cause  of  Sleep.  II.— Insomnia  or  Wake- 
fulness. III.— Remedies  for  Insomnia.  IV. — Treatment  of 
Insomnia.  V.— Dreams.  VI.— Somnambulism.  VII— Arti- 
ficial Somnambulism  or  Hypnotism. 


'Insomnia  and  Other  Disorders  of  Sleep,'  by  Dr.  Henry  M.  Lyman.  (Chicago:  W.  T. 
Keener  i,  is  a  medical  book  whose  matter  and  style  carry  it  into  the  higher  grades  of  literature. 
It  represents  thought  and  knowledge,  and  to  students  interested  in  psychical  research  the 
last  half  of  the  book  should  be  useful  and  attractive.  The  first  half  is  limited  in  its  adapta- 
bility to  practising  physicians. — The  Nation. 

It  is  pleasant  to  find  a  book  which  is  clearly  the  result  of  a  natural  literary  effort  and 
the  author's  fondness  for  his  theme— a  book  not  written  to  "  suppy  a  long-felt  want "  or  "  to  fill 
an  existing  gap."  Dr.  Lyman's  is  such  a  one,  and  shows  that  the  subject  of  which  he  writes 
has  been  a  pleasant  study.  It  is  readable  and  full  of  interest,  and  is  quite  up  to  the  times, 
which  is  important,  as  the  last  work  upon  Sleep,  a  very  good  one  by  the  way,  was  written  by 
Dr.  Hammond  nearly  fifteen  years  ago.  Dr.  Lyman  agrees  with  Mosso  that  sleep  depends 
rather  upon  molecular  disturbance  than  upon  fluctuations  in  the  blood-supply,  which  is  the 
modern  and  generally  accepted  theory. 

His  considerations  of  the  pathological  states  which  induce  wakefulness  are  especially  full 
and  practical,  and  his  therapeutical  suggestions,  despite  a  tendency  to  polypharmacy  and 
rather  heavy  dosage,  are  in  the  main  excellent. — The  New  York  Medical  Journal. 

Those  who  would  like  to  acquaint  themselves  with  what  science  has  to  say  on  these 
topics  and  learn  how  they  are  regarded  by  the  wisest  students  of  this  age,  may  turn  with 
profit  to  the  pages  of  this  book.  The  author  is  well  known,  not  only  as  a  skilled  physician 
and  accomplished  teacher,  but  as  one  of  the  most  polished  writers  of  the  American  Medical 
Press. — Philadelphia  Medical  and  Surgical  Reporter. 

The  author  has  evidently  brought  to  bear  upon  the  subject,  extended  research,  and 
close  observation.  Insomuch  that  there  are  few  medical  practitioners  who  may  not  find  in  it 
much  that  is  both  interesting  and  profitable,  that  is  practical  *  *  *  *  *  It  is  the  best  book 
on  the  subject. — The  Sanitarian. 


OXE  VOLIME.     \*m\.    CLOTH,  81.50. 


A /so  80  J    W.   Harrison  Si. 


W.    T.    KEENER, 

Medical  Publisher,  Importer  and  Bookseller, 

96  Washington  St.,  CHICAGO. 


RECTAL  AND  ANAL  SURGERY, 

WITH   A   DESCRIPTION   OF   THE  < 

SECRET  METHODS  OF  THE  ITINERANTS. 

BY    EDMUND   ANDREWS,   A.M.,    M.D.,    LL.D. 

Senior  Surgeon  of  Mercy  Hospital,  Professor  of  Clinical  Surgery  in  Chicago  Medical  College 

— and — 

E.   WYLLYS   ANDREWS,   A.M.,    M.D. 

Surgeon  of  Mercy  Hospital  and  Adjunct  Professor  of  Clinical  Surgery  in  Chicago 

Medical  College. 

SECOND  EDITION.      REVISED  AND  ENLARGED. 


The  rapid  sale  of  the  First  Edition  now  compels  the  publication  of  a 
Second  Edition,  which  has  been  entirely  rewritten  and  considerably  enlarged. 

While  still  keeping  to  the  idea  of  a  practical  working  treatise,  rather  than 
one  devoted  to  the  historical  and  theoretical  sides  of  the  subject,  it  has  been 
felt  necessary  in  the  new  edition  to  introduce  a  chapter  upon  the  special 
Anatomy  of  the  Rectum  and  Anal  Region,  for  ready  reference  in  daily  prac- 
tice, and  to  make  clear  and  unmistakable  the  exposure  of  that  shallow  pseudo- 
pathology  which  ignorant  or  venal  specialists  have  tried  to  foist  upon  the 
public  and  even  upon  the  profession. 

A  new  chapter  has  also  been  added  upon  "  Proctitis  "  and  its  most  ap- 
proved treatment. 

In  the  matter  of  new  operations,  such  as  Whitehead's,  an  endeavor  has 
been  made  to  introduce  the  latest  results  of  clinical  trial  as  found  in  periodi- 
cal literature  down  to  the  time  of  publication,  as  well  as  in  the  newer  treatises. 

The  subject  of  Anal  Fissure  has  been  more  fully  examined  and  illustrated 
than  in  the  last  edition,  and  all  the  known  methods  of  treatment,  including 
the  itinerant  and  the  so-called  "  systems,"  carefully  considered. 

It  has  been  the  endeavor  in  this  edition,  as  in  the  former,  to  give  relatively 
a  large  place  to  the  more  common  Rectal  Diseases  which  are  so  constantly 
coming  before  the  practitioner,  and  less  to  the  rare  and  unusual  cases  which 
practically  are  of  less  moment. 

Accompanying  the  general  descriptions  of  the  various  forms  of  treatment, 
the  formulae  which  experience  has  proven  most  useful  have  invariably  been 
introduced.  The  aim  has  been  to  select  these  formulas  so  far  as  possible  from 
the  best  sources,  eliminating  those  which  are  untried  or  have  not  stood  the 
test  of  trial. 

Another  new  feature  is  the  Foemulaby  at  the  close  of  the  book,  containing 
over  fifty  practical  working  prescriptions,  and  including  all  of  any  note  of 
the  best  Foreign  and  American  surgeons,  as  well  as  some  new  ones,  and  those 
employed  by  traveling  or  local  "Rectal  Specialists"  for  injection  of  haemor- 
rhoids and  other  purposes. 

This  Formulary  may  be  relied  upon  as  nearly  a  complete  compilation  of 
the  remedies  advised  by  Curling,  Van  Buren,  Ball,  Kelsey,  Allingham,  Esmarch 
and  others,  and,  for  hurried  reference,  it  is  believed  it  will  be  found  a  prac- 
tical benefit  to  the  average  practitioner  and  oftentimes  save  him  the  turning 
over  of  many  volumes  when  time  is  precious. 


One  Volume,  8vo,  Cloth.    Profusely  Illustrated.    SI. 50  net. 
Mailed,  Postpaid,  on  Receipt  of  Prioe. 

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